Category Archives: Health Care Fraud

Durable Medical Equipment Clinic Owner Sentenced for His Role in $11 Million Health Care Fraud Scheme

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The former owner of a defunct durable medical equipment (DME) clinic was sentenced today in Miami to serve 70 months in prison for his role in an $11 million health care fraud scheme involving World Class Medical Clinic Corp. (World Class).
Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney for the Southern District of Florida Wifredo A Ferrer;  Special Agent in Charge Michael B. Steinbach of the FBI’s Miami Field Office, and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) Office of Investigation’s Miami Office  made the announcement.
Francisco Enrique Chavez, 36, of Miami, was sentenced by U.S. District Judge Patricia A. Seitz in the Southern District of Florida.   In addition to his prison term, Chavez  was sentenced to three years of supervised release and ordered to pay $1,713,959 in restitution.
On Nov. 21, 2013, Chavez pleaded guilty to one count of health care fraud.
During the course of the health care fraud scheme, Chavez  served as the president and sole corporate officer of World Class, a defunct DME company located in Miami.   From March 27, 2006 through Aug. 22, 2006, Chavez submitted and caused to be submitted approximately $11.3 million in false and fraudulent claims to the Medicare program on behalf of World Class for DME that was neither prescribed by a physician nor medically necessary.   Medicare paid more than $1.7 million on these false and fraudulent claims.   The proceeds of the World Class fraud scheme were deposited into corporate bank accounts that were controlled by Chavez.   Chavez, in turn, made numerous cash withdrawals and deposits into personal and shell entity bank accounts to facilitate and conceal the nature of the scheme.
The case is being investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida.   The case is being prosecuted by  Allan J. Medina and Sarah M. Hall of the Fraud Section .
Since their inception in March 2007, Medicare Fraud Strike Force operations in nine locations have charged more than 1,700 defendants who collectively have falsely billed the Medicare program for more than $5.5 billion.   In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Leader of $28.3 Million Medicare Fraud Scheme Pleads Guilty

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A Florida man who had been the owner and operator of multiple physical therapy rehabilitation facilities pleaded guilty today for his role in organizing and leading a $28.3 million Medicare fraud scheme involving physical and occupational therapy services.
Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, Acting U.S. Attorney A. Lee Bentley III of the Middle District of Florida, Special Agent in Charge Paul Wysopal of the FBI’s Tampa Field Office and Special Agent in Charge Christopher B. Dennis of the U.S. Health and Human Services Office of Inspector General (HHS-OIG) region including all of Florida made the announcement.
Luis Duluc, 53, formerly of southwest Florida, pleaded guilty in the U.S. District Court for the Middle District of Florida to conspiracy to commit health care fraud and making a false statement relating to health care matters.   His sentencing date will be set by the court.   He faces a maximum penalty of 15 years in prison.
According to documents filed in the case, Duluc and his co-conspirators used various physical therapy clinics and other business entities throughout Florida and elsewhere to submit approximately $28,347,065 in fraudulent reimbursement claims to Medicare from 2005 through 2009.   Medicare paid approximately $14,424,865 on those claims.
Duluc was chairman and president of a Delaware holding company known as Ulysses Acquisitions Inc.   Duluc and his co-conspirators used Ulysses Acquisitions to purchase comprehensive outpatient rehabilitation facilities (CORFs) and outpatient physical therapy providers (OPTs) including West Coast Rehab Inc. in Fort Myers, Fla.; Rehab Dynamics Inc. in Venice, Fla.; Polk Rehabilitation Inc. in Lake Wales, Fla.; and Renew Therapy Center of Port St. Lucie LLC in Port St. Lucie, Fla., in order to gain control of these clinics’ Medicare provider numbers.
Working with co-conspirators in Miami and elsewhere, Duluc obtained identifying information of Medicare beneficiaries by paying kickbacks and stealing beneficiaries’ identifying information.   Duluc and his co-conspirators also obtained unique identifying information of physicians.   They then used this information to create and submit false claims to Medicare through the clinics Ulysses Acquisitions purchased.   These claims sought reimbursement for therapy services that were not legitimately prescribed and not actually provided.   The conspirators created and used false and forged patient records in an effort to conceal the fact that services had not actually been provided.
Part of the conspiracy included what came to be known as the 80/20 deal, which Duluc developed and marketed.   The 80/20 deal involved extensive kickback arrangements with co-conspirators who owned other therapy clinics that were used to further the overall fraud scheme.   For example, Duluc and co-conspirators used the clinics they controlled to submit false reimbursement claims to Medicare on behalf of Miami-based therapy clinics such as Hallandale Rehabilitation Inc., Tropical Physical Therapy Corporation, American Wellness Centers Inc., and West Regional Center Inc.   Duluc and co-conspirators would retain approximately 20 percent of the money Medicare paid on these claims and pay the other 80 per cent of the fraud proceeds to the co-conspirator clinic owners.
When Duluc and his co-conspirators were done using the clinics they acquired through Ulysses Acquisitions, they engaged in sham sales of the clinics to nominee or straw owners, all of whom were recent immigrants to the United States who had no background or experience in the health care industry.   Duluc did this in an effort to try to disassociate himself from the fraudulent operations of the rehabilitation facilities.
This case is being investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Middle District of Florida.   This case is being prosecuted by Trial Attorneys Christopher J. Hunter and Andrew H. Warren of the Criminal Division’s Fraud Section and Assistant United States Attorney Simon A. Gaugush of the U.S. Attorney’s Office for the Middle District of Florida.
Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion.   In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Three Miami Residents Indicted for Alleged Roles in $190 Million Medicare Fraud Scheme

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Three Miami residents have been indicted for their alleged participation in a $190 million Medicare fraud scheme.
Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Special Agent in Charge Michael B. Steinbach of the FBI’s Miami Field Office; and Special Agent in Charge Christopher B. Dennis of the U.S. Health and Human Services Office of Inspector General (HHS-OIG) Office of Investigations Miami Office made the announcement after the indictment was unsealed.
On Jan. 28, 2014, a federal grand jury in Miami returned a 10-count indictment charging Nelson Rojas, 43, Roger Bergman, 64, and Rodolfo Santaya, 54, for allegedly participating in a scheme to defraud Medicare by submitting false and fraudulent claims, from approximately December 2002 to October 2010.
Rojas was charged with conspiracy to pay and receive bribes and kickbacks in connection with a federal health care program, conspiracy to commit money laundering, two counts of money laundering and one count of aggravated identity theft.   Bergman and Santaya were each charged with conspiracy to commit health care fraud and wire fraud.   In addition, Bergman was charged with conspiracy to make false statements relating to health care matters.   Santaya was also charged with conspiracy to pay and receive bribes and kickbacks in connection with a federal health care program, as well as two counts of receiving bribes and kickbacks in connection with a federal health care benefit program.
According to the indictment, Rojas, Bergman and Santaya allegedly participated in a scheme orchestrated by the owners and operators of American Therapeutic Corporation (ATC) and its management company, Medlink Professional Management Group Inc.   ATC and Medlink were Florida corporations headquartered in Miami.   ATC operated purported partial hospitalization programs (PHPs), a form of intensive treatment for severe mental illness, in seven different locations throughout South Florida.   Both corporations have been defunct since October 2010.
The indictment alleges that Bergman was a licensed physician’s assistant who participated in the scheme by, among other things, admitting Medicare beneficiaries to ATC facilities for PHP treatment even though they did not quality for such treatment and falsifying patient records to make it appear as though patients needed, qualified for and actually received legitimate PHP treatment when they did not.   The indictment alleges that Santaya served as a patient recruiter who provided ineligible patients to ATC in exchange for kickbacks.   The indictment alleges that Rojas was the co-owner of a check cashing business and that he facilitated the payments of bribes and kickbacks from ATC to various patient recruiters.
ATC, Medlink and various owners, managers, doctors, therapists, patient brokers and marketers of ATC and Medlink have pleaded guilty or have been convicted at trial.   In September 2011, ATC owner Lawrence Duran was sentenced to 50 years in prison for his role in orchestrating and executing the scheme to defraud Medicare.
The charges and allegations contained in the indictment are merely accusations, and the defendants are presumed innocent unless and until proven guilty.
The case is being investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida.   The case is being prosecuted by Assistant Chief Robert A. Zink and Trial Attorney Nicholas E. Surmacz.
Since their inception in March 2007, Medicare Fraud Strike Force operations in nine locations have charged more than 1,700 defendants who collectively have falsely billed the Medicare program for more than $5.5 billion.   In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Patient Recruiter Pleads Guilty in Connection With $13 Million Health Care Fraud Scheme

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Pavel Zborovskiy, 57, of Brooklyn, N.Y., pleaded guilty today to conspiracy to pay and receive illegal health care kickbacks in connection with a $13 million health care fraud and money laundering scheme.
Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney Loretta E. Lynch of the Eastern District of New York, Assistant Director in Charge George Venizelos of the FBI’s New York Field Office, and Special Agent in Charge Thomas O’Donnell of the U.S. Department of Health and Human Services’ Office of Inspector General (HHS-OIG) made the announcement.
Zborovskiy pleaded guilty before U.S. District Judge Nina Gershon of the Eastern District of New York and is the sixth defendant to plead guilty in connection with the scheme.   At sentencing on May 28, 2014, Zborovskiy faces a maximum penalty of five years in prison and a fine of more than $2.5 million.
According to court documents, from 2010 to 2012, Zborovskiy, working through an ambulette company, recruited patients to attend a Brooklyn clinic called Cropsey Medical Care PLLC.   An ambulette is a vehicle that is licensed by New York State’s Medicaid program to transport beneficiaries to and from medical facilities when such transportation is medically necessary.   Zborovskiy’s ambulette company transported the patients he had recruited to and from Cropsey Medical, and billed Medicaid for such transportation.   Once Zborovskiy’s beneficiaries were transported to Cropsey Medical, Zborovskiy and others paid such beneficiaries cash kickbacks to induce them to continue to attend the clinic and to receive medically unnecessary physical therapy, diagnostic testing and other services.   Such purported medical services were then billed by Cropsey Medical to Medicare and Medicaid.
According to court documents, from approximately November 2009 to October 2012, Cropsey Medical submitted more than $13 million in claims to Medicare and Medicaid, seeking reimbursement for a wide variety of fraudulent medical services and procedures, including physician office visits, physical therapy and diagnostic tests.
The case was investigated by the FBI and HHS-OIG and brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and U.S. Attorney’s Office for the Eastern District of New York.   The case is being prosecuted by Trial Attorney Sarah M. Hall of the Criminal Division’s Fraud Section and Assistant U.S. Attorney Shannon Jones of the Eastern District of New York.
Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion.   In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Medicare Fraud Strike Force Set Record Numbers for Health Care Fraud Prosecutions

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The Justice Department’s Medicare Fraud Strike Force has set record numbers for health care prosecutions in Fiscal Year 2013, demonstrating the targeted and coordinated approach remains strong as the strike force enters its eighth year of fighting fraud against the government’s health care programs.
“These record results underscore our determination to hold accountable those who take advantage of vulnerable populations, commit fraud on federal health care programs, and place the safety of others at risk for illicit financial gain,” said Attorney General Eric Holder.   “By targeting our enforcement efforts to ‘hot spots’ in nine cities, the Medicare Fraud Strike Force is allowing us to fight back more effectively than ever before.”
“The Medicare Fraud Strike Force is one of this country’s most productive investments,” said Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division.   “We are not only putting hundreds of criminals who steal from Medicare in prison, but also stopping their theft in its tracks, recovering millions of dollars for taxpayers, and deterring potential criminals who ultimately decide the crime isn’t worth it.”
“Those perpetrating Medicare fraud cheat both taxpayers and vulnerable patients, and our Strike Forces are successfully fighting back – holding criminals accountable and recovering stolen dollars,” said Inspector General Daniel R. Levinson of the U.S. Department of Health and Human Services.   “Our joint commitment to bring the fight against fraud to criminal hotspots around the country is steadfast.”
Under the supervision of the Criminal Division and U.S. Attorney’s Offices, the Medicare Fraud Strike Force is formed by coordinated teams of investigators and prosecutors – including personnel from the Justice Department, the U.S. Department of Health and Human Services and the FBI – who analyze Medicare claims data to target specific geographic areas showing unusually high levels of Medicare billing.
By focusing on the worst offenders engaged in current fraud schemes in the highest intensity regions, the strike force seeks to deter fraud in the target community and prevent it from spreading to other areas.   The strike force is currently operating in nine cities: Baton Rouge, La.; Brooklyn, N.Y.; Chicago; Dallas; Detroit; Houston; Los Angeles; Miami and Tampa, Fla.   S ince its inception in March 2007, strike force prosecutors have charged more than 1,700 defendants who have collectively billed the Medicare program more than $5.5 billion.
In Fiscal Year 2013, the strike force set records in the number of cases filed (137), individuals charged (345), guilty pleas secured (234) and jury trial convictions (46).   In addition, the defendants who were charged and sentenced are facing significant time in prison – an average of 52 months in prison for those sentenced in FY 2013, and an average of 47 months in prison for those sentenced since 2007.
According to a recent report by the Inspector General for the U.S. Department of Health and Human Services, for every dollar the Departments of Justice and Health and Human Services have spent fighting health care fraud, they have returned an average of nearly eight dollars to the U.S. Treasury, the Medicare Trust Fund and others.
The Medicare Fraud Strike Force is part of an unprecedented partnership between the Departments of Justice and Health and Human Services called HEAT (Health care Enforcement and Prevention Action Team).   Formed in May 2009, this partnership brings together high-level leaders from both departments to share information, spot trends, coordinate strategy and strengthen our fraud prevention efforts.

Disbarred Attorney Pleads Guilty for Role in $28.3 Million Medicare Fraud Scheme

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A North Carolina woman has pleaded guilty for her involvement in a $28.3 million Medicare fraud scheme involving physical and occupational therapy services.
Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, Acting U.S. Attorney A. Lee Bentley III of the Middle District of Florida, Special Agent in Charge Paul Wysopal of the FBI’s Tampa Field Office and Special Agent in Charge Christopher Dennis of the U.S. Health and Human Services Office of Inspector General (HHS-OIG) made the announcement.
Margarita M. Grishkoff, 59, of Charlotte, N.C., and formerly of southwest Florida, pleaded guilty today in the U.S. District Court for the Middle District of Florida to conspiracy to commit health care fraud.   Her sentencing date will be set by the court.    She faces a maximum penalty of 10 years in prison.
According to documents filed in the case, Grishkoff and her co-conspirators used various physical therapy clinics and other business entities throughout Florida and elsewhere to submit approximately $28.3 million in fraudulent reimbursement claims to Medicare from 2005 through 2009.    Medicare paid approximately $14.4 million on those claims.
Grishkoff, a former attorney who was disbarred in 1997, was vice president, director and registered agent in Florida for a Delaware holding company known as Ulysses Acquisitions Inc.    Grishkoff and co-conspirators used Ulysses Acquisitions to purchase comprehensive outpatient rehabilitation facilities and outpatient physical therapy providers, including West Coast Rehab Inc. in Fort Myers, Fla.; Rehab Dynamics Inc. in Venice, Fla.; Polk Rehabilitation Inc. in Lake Wales, Fla.; and Renew Therapy Center of Port St. Lucie LLC in Port St. Lucie, Fla., to gain control of these clinics’ Medicare provider numbers.
Working with co-conspirators in Miami and elsewhere, Grishkoff and her co-conspirators obtained identifying information of Medicare beneficiaries through paying kickbacks.    They also obtained unique identifying information of physicians.   Grishkoff and her co-conspirators then used this information to create and submit false claims to Medicare through the clinics Ulysses Acquisitions purchased.    These claims sought reimbursement for therapy services that were not legitimately prescribed and not actually provided.
Grishkoff and co-conspirators also paid kickbacks to co-conspirators who owned other therapy clinics that were used to further the fraud scheme.    For example, Grishkoff and co-conspirators used the clinics they controlled to submit false reimbursement claims to Medicare on behalf of Miami-based therapy clinics such as Hallandale Rehabilitation Inc., Tropical Physical Therapy Corporation, American Wellness Centers Inc., and West Regional Center Inc.    Grishkoff and co-conspirators would retain approximately 20 percent of the money Medicare paid on these claims and pay the other 80 percent of the fraud proceeds to the co-conspirator clinic owners.
When Grishkoff and her co-conspirators were done using the clinics they acquired through Ulysses Acquisitions, they engaged in sham sales of the clinics to nominee or straw owners, all of whom were recent immigrants to the United States with no background or experience in the health care industry.    Grishkoff and others did this in an effort to try to disassociate themselves from the fraudulent operations of their clinics.
This case is being investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Middle District of Florida.    This case is being prosecuted by Trial Attorneys Christopher J. Hunter and Andrew H. Warren of the Criminal Division’s Fraud Section and Assistant United States Attorney Simon A. Gaugush of the U.S. Attorney’s Office for the Middle District of Florida.
Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion.    In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Home Health Agency Owner Sentenced for Role in $11 Million Detroit Medicare Fraud Scheme

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A home health agency owner who participated in a Medicare fraud scheme that totaled almost $11 million was sentenced in Detroit today to serve 120 months in prison.
Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney for the Eastern District of Michigan Barbara L. McQuade, Special Agent in Charge Robert D. Foley III of the FBI’s Detroit Field Office and Special Agent in Charge Lamont Pugh III of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) Chicago Regional Office made the announcement.
Chiradeep Gupta, 39, was sentenced by U.S. District Judge Denise Page Hood in the Eastern District of Michigan.  In addition to his prison term, Gupta was sentenced to serve three years of supervised release and was ordered to pay more than $10 million in restitution, jointly and severally with his co-defendants.
On Oct. 26, 2012,  Gupta, a physical therapist and part-owner of All American, a home health care company located in Oak Park, Mich., was found guilty at trial of one count of conspiracy to commit health care fraud, one count of conspiracy to commit money laundering and three substantive counts of money laundering.
According to evidence presented at trial, Gupta and his co-conspirators caused the submission of false and fraudulent claims to Medicare through All American and Patient Choice, another Oak Park-based home health care company, which purported to provide skilled nursing and physical therapy services to Medicare beneficiaries in the greater Detroit area.
The evidence showed that Gupta and his co-conspirators used patient recruiters, who paid Medicare beneficiaries to sign blank documents for physical therapy services that were never provided and/or medically unnecessary.  The owners of Patient Choice and All American paid physicians to sign referrals and other therapy documents necessary to bill Medicare.  Physical therapists and physical therapist assistants provided through contractors, including two owned by Gupta, would then create fake medical records using the blank, pre-signed forms obtained by the patient recruiters to make it appear as if physical therapy services had actually been rendered, when, in fact, the services had not been rendered.
According to evidence presented at trial, Gupta provided to Patient Choice and All American physical therapists and physical therapist assistants who created fake patient files using blank, pre-signed forms obtained by patient recruiters to make it appear as if the physical therapy services billed to Medicare had actually been provided.  Gupta also doctored and directed the doctoring of fake patient files.  The evidence at trial showed that Gupta laundered the proceeds of the fraud through multiple shell companies.
This case was investigated by the FBI, HHS-OIG and the Internal Revenue Service and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Eastern District of Michigan. This case was prosecuted by Deputy Chief Gejaa Gobena, Assistant Chief Catherine Dick and Trial Attorney Niall O’Donnell of the Criminal Division’s Fraud Section.
Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion.   In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers.

Owner of Houston Medical Equipment Companies Indicted for $3.4 Million Medicare Fraud Scheme

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Huey P. Williams Jr., the owner and operator of two durable medical equipment (DME) companies, was arrested yesterday for his alleged role in a $3.4 million Medicare fraud scheme.
Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney Kenneth Magidson of the Southern District of Texas, Special Agent in Charge Stephen L. Morris of the FBI’s Houston Field Office, Special Agent in Charge Mike Fields of the Dallas Regional Office of HHS’s Office of the Inspector General (HHS-OIG), and the Texas Attorney General’s Medicaid Fraud Control Unit (MFCU) made the announcement.
The indictment charges Williams, 44, of Katy, Texas, with one count of health care fraud, which carries a maximum penalty of 10 years in prison upon conviction.   Williams is expected to make his initial appearance in U.S. District Court for the Southern District of Texas in Houston.
According to the indictment, Williams orchestrated and executed a scheme to defraud Medicare beginning in 2006 and continuing until July 2010.   Williams allegedly submitted false and fraudulent claims to Medicare through his Houston-area DME companies – Hermann Medical Supplies Inc. and Hermann Medical Supplies II (Hermann Medical) – which purported to provide orthotics and other DME to Medicare beneficiaries.
Hermann Medical allegedly submitted claims to Medicare for DME, including orthotic devices, which were medically unnecessary and/or never provided.   Many of the orthotic devices were components of an arthritis kit and were purported to be for the treatment of arthritis-related conditions.   From December 2006 through July 2010, Williams submitted claims of approximately $3.4 million to Medicare.
An indictment is merely a formal accusation.   Defendants are presumed innocent unless and until proven guilty beyond a reasonable doubt in a court of law.
The case was investigated by the FBI, HHS-OIG and MFCU and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Texas.   The case is being prosecuted by Trial Attorney Ashlee Caligone McFarlane of the Fraud Section.
Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion.   In addition, HHS’s Centers for Medicare & Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers.

Nationwide Contract Therapy Providers to Pay $30 Million to Resolve False Claims Act Allegations

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Contract therapy providers RehabCare Group Inc., RehabCare Group East Inc. and Rehab Systems of Missouri and management company Health Systems Inc. have agreed to pay $30 million to resolve claims that they violated the False Claims Act by engaging in a kickback scheme related to the referral of nursing home business, the Justice Department announced today.   Additionally, as part of this settlement, the entities have agreed to restructure their business arrangement.

“Health care providers that attempt to profit from illegal kickbacks will be held accountable,” said Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery.  “We will continue to advocate for the appropriate use of Medicare funds and the proper care of our senior citizens.”

Between March 1, 2006, and Dec. 31, 2011, RehabCare allegedly arranged with Rehab Systems of Missouri to obtain Rehab Systems of Missouri ’s contracts to provide therapy to patients residing in 60 nursing homes controlled by Rehab Systems  majority-owner James Lincoln.   In exchange for this stream of referrals, RehabCare allegedly paid Rehab Systems  a $400,000 to $600,000 upfront payment and allowed Rehab Systems to retain a percentage of the revenue generated by each referral.

“The Anti-Kickback Statute is intended to protect patients and federal health care programs from fraud and abuse,” said Acting U.S. Attorney for the District of Minnesota John Marti.   “We will remain vigilant in pursuing entities that improperly further their financial interest at the expense of the Medicare Trust Fund.”

“This settlement sends a message to those who seek to improperly take advantage of the Medicare program,” said U.S. Department of Health and Human Services Office of Inspector General Special Agent in Charge Gerald T. Roy.   “The Office of the Inspector General, Kansas City Regional Office will continue to work aggressively to eliminate this type of misconduct from our health care system.”

“The FBI will continue to work with its partners to combat this type of abuse,” said Special Agent in Charge of the FBI’s Minneapolis Office J. Chris Warrener.   “It remains committed to the elimination of fraud to ensure the integrity of federal health care programs.”

This civil 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, which was announced in May 2009 by Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sebelius.  The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.  One of the most powerful tools in this effort is the False Claims Act.  Since January 2009, the Justice Department has recovered more than $17.1 billion through False Claims Act cases, with more than $12.2 billion of that amount recovered in cases involving fraud against federal health care programs.

The settlement resolves allegations originally brought in a lawsuit filed by a whistleblower under the qui tam provisions of the False Claims Act, which allow private parties to bring suit on behalf of the government and to share in any recovery.  The whistleblower will receive $700,000 as its share of the recovery in this case.                

The case was handled by the U.S. Attorney’s Office for the District of Minnesota with assistance from the Justice Department’s Civil Division, the U.S. Attorney’s Office for the Eastern District of Missouri, the Federal Bureau of Investigation and the U.S. Department of Health and Human Services Office of Inspector General.  This action was supported by the Elder Justice and Nursing Home Initiative that coordinates the department’s activities combating elder abuse, neglect and financial exploitation, especially as they impact beneficiaries of Medicare, Medicaid and other federal health care programs.

The lawsuit is captioned U.S. ex rel. Health Dimensions Rehabilitation Inc. v. RehabCare Group Inc., et. al., Case No. 4:12-cv-00848 AGF (E.D. Mo.).   The claims settled by this agreement are allegations only; there has been no determination of liability.

Miami Patient Recruiter Pleads Guilty for Role in $190 Million Medicare Fraud Scheme

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A patient recruiter for a fraudulent Miami-area mental health company, American Therapeutic Corporation (ATC), pleaded guilty today for her participation in a $190 million Medicare fraud scheme.
Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida, Special Agent in Charge Michael B. Steinbach of the FBI’s Miami Field Office and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) Office of Investigations Miami Office made the announcement.
Miami resident Mayelin Santoyo, 28, pleaded guilty before U.S. District Judge K. Michael Moore in the Southern District of Florida to one count of conspiracy to receive health care kickbacks.   Sentencing has been scheduled for March 28, 2014.    On Nov. 25, 2013, co-defendant Jose Martin Olivares, 36, also a Miami resident and patient recruiter, pleaded guilty to one count of conspiracy to receive health care kickbacks before U.S. District Judge Donald L. Graham for his role in this scheme.   Olivares’s sentencing is set for Feb. 4, 2014.
According to court documents, Santoyo was a patient recruiter for the now-defunct ATC.   ATC and its management company, Medlink Professional Management Group Inc., were Florida corporations headquartered in Miami.   ATC operated purported partial hospitalization programs (PHPs), a form of intensive treatment for severe mental illness, in seven different locations throughout South Florida and Orlando.
Santoyo recruited Medicare beneficiaries to attend ATC’s PHP program in exchange for kickbacks in the form of checks and cash.   The amounts of the kickbacks were based on the number of days each recruited patient spent at ATC.   Santoyo knew that the patients she recruited for ATC were not qualified to receive PHP treatment.
ATC’s owners and operators paid millions of dollars in kickbacks to the owners and operators of various assisted living facilities and halfway houses, as well as to patient recruiters, like Santoyo, in exchange for delivering ineligible patients to ATC.   According to court documents, to obtain the cash required to support the kickbacks to recruiters such as Santoyo, the co-conspirators laundered millions of dollars of payments from Medicare.
In related cases, ATC, Medlink and various owners, managers, doctors, therapists and patient recruiters of ATC and Medlink have already pleaded guilty or have been convicted at trial.    In September 2011, ATC’s owner, Lawrence Duran, was sentenced to 50 years in prison for his role in orchestrating and executing the scheme to defraud Medicare.
This case was investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida.   The case was prosecuted by Assistant Chief Robert A. Zink and Trial Attorney Anne P. McNamara of the Criminal Division’s Fraud Section.
Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion.   In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.