Archive for the ‘Fraud’ Category

Miami Home Health Patient Recruiter and Therapy Staffing Company Owner Plead Guilty in $7 Million Health Care Fraud Scheme

August 22, 2013

A patient recruiter and a therapy staffing company owner pleaded guilty today in connection with a $7 million health care fraud scheme involving the now defunct home health care company Anna Nursing Services Corp.

Ivan Alejo, 48, and Hugo Morales, 36, pleaded guilty before U.S. District Judge Jose E. Martinez in the Southern District of Florida to one count of conspiracy to commit health care fraud.  At sentencing, scheduled for Nov. 5, 2013, Alejo and Morales each face a maximum penalty of 10 years in prison.

Alejo worked as a patient recruiter at Anna Nursing, a home health care agency in Miami Springs, Fla., that purported to provide home health and therapy services to Medicare beneficiaries but in reality billed Medicare for expensive physical therapy and home health care services that were not medically necessary and/or were not provided.  Morales owned Professionals Therapy Staffing Services Inc., which provided therapists to Anna Nursing.

Alejo and his co-conspirators negotiated and paid kickbacks and bribes to patient recruiters in return for the recruiters providing patients to Anna Nursing for home health and therapy services that were medically unnecessary and/or not provided.  He and others also paid kickbacks and bribes to co-conspirators in doctors’ offices and clinics in exchange for home health and therapy prescriptions, medical certifications, and other documentation.  Alejo and his co-conspirators would use the prescriptions, medical certifications and other documentation to fraudulently bill the Medicare program for home health care services.

Morales and others created fictitious progress notes and other patient files indicating that therapists from Professionals Therapy had provided physical or occupational therapy services to particular Medicare beneficiaries, when in many instances those services had not been provided and/or were not medically necessary.  Morales knew the falsified documents were used to support false claims for home health care services billed to Medicare by his co-conspirators at Anna Nursing.

From approximately October 2010 through approximately April 2013, Anna Nursing was paid by Medicare approximately $7 million for fraudulent claims for home health care services that were not medically necessary and/or not provided.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,500 defendants who have collectively billed the Medicare program for more than $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.

HCAF supports the Office of Inspector General and the Department of Justice in eliminating fraud in the home health industry. Removing these bad actors is paramount to protecting home health’s status as an upstanding player in the healthcare arena.

To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to:www.stopmedicarefraud.gov.

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Health Care Clinic Owners Plead Guilty in Miami for Roles in $8 Million Health Care Fraud Scheme

August 14, 2013

Two health care clinic owners pleaded guilty today in connection with an $8 million health care fraud scheme involving the now-defunct home health care company Flores Home Health Care Inc.

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 Miami office of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) Office of Investigations made the announcement.

Miguel Jimenez, 43, and Marina Sanchez Pajon, 29, of Miami, pleaded guilty before U.S. District Judge Ursula Ungaro in the Southern District of Florida, each to one count of conspiracy to commit health care fraud. At sentencing, scheduled for Oct. 30, 2013, Jimenez and Pajon each face a maximum penalty of 10 years in prison.

Jimenez and Pajon, who are married, were owners and operators of Flores Home Health, a Miami home health care agency that purported to provide home health and physical therapy services to Medicare beneficiaries.

According to court documents, Jimenez and Pajon operated Flores Home Health for the purpose of billing Medicare for, among other things, expensive physical therapy and home health care services that were not medically necessary and/or were not provided. Jimenez’s primary role at Flores Home Health involved controlling the company and running and overseeing the schemes conducted through Flores Home Health. Both Jimenez and Pajon were responsible for negotiating and paying kickbacks and bribes, interacting with patient recruiters, and coordinating and overseeing the submission of fraudulent claims submitted to the Medicare program.

Jimenez, Pajon and their co-conspirators paid kickbacks and bribes to patient recruiters in return for the recruiters providing patients to Flores Home Health for home health and therapy services that were medically unnecessary and/or not provided. They also paid kickbacks and bribes to co-conspirators in doctors’ offices and clinics in exchange for home health and therapy prescriptions, medical certifications, and other documentation. Jimenez, Pajon, and their co-conspirators used the prescriptions, medical certifications, and other documentation to fraudulently bill Medicare for home health care services that Jimenez and Pajon knew were in violation of federal criminal laws.

From approximately October 2009 through approximately June 2012, Flores Home Health was paid approximately $8 million by Medicare for fraudulent claims for home health services that were not medically necessary and/or not provided.

The 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. This case was prosecuted by Trial Attorney A. Brendan Stewart 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 1,500 defendants who have collectively billed the Medicare program for more than $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.

To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to: http://www.stopmedicarefraud.gov.

13-913

Criminal Division

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OIG Exclusions & Sanctions Listing Updated for August

August 9, 2013

HCAF has posted the latest exclusion and reinstatements that were released by CMS’ Office of the Investigator General (OIG) on August 8, 2013. The list includes physicians and other provider types in Florida.

Health care providers must be careful not to make payments to sanctioned entities or employ sanctioned individuals. No payment will be made by any federal health care program for any items or services furnished, ordered, or prescribed by an excluded individual or entity. Federal health care programs include Medicare, Medicaid, and all other plans and programs that provide health benefits funded directly or indirectly by the United States.

The basis for exclusion includes convictions for program-related fraud and patient abuse, licensing board actions and default on Health Education Assistance Loans.

Please compare your referring physicians, employees or vendors against the listing of excluded individuals.

Click here to access the updated OIG list.

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U.S. Intervenes in False Claims Act Lawsuit Against Fla. Home Health Care Company and Its Owner

July 22, 2013

The government has intervened in a whistleblower lawsuit against A Plus Home Health Care, Inc., a home health care company in Fort Lauderdale, Fla., and its owner, Tracy Nemerofsky, the Justice Department announced today. The government alleges that A Plus offered referring physicians’ spouses sham marketing positions with the company to induce the physicians to refer Medicare patients for home health care services. (more…)

OIG Exclusions & Sanctions Listing Updated for July

July 12, 2013

HCAF has posted the latest exclusion and reinstatements that were released by CMS’ Office of the Investigator General (OIG) on July 10, 2013. The list includes physicians and other provider types in Florida.

Health care providers must be careful not to make payments to sanctioned entities or employ sanctioned individuals. No payment will be made by any federal health care program for any items or services furnished, ordered, or prescribed by an excluded individual or entity. Federal health care programs include Medicare, Medicaid, and all other plans and programs that provide health benefits funded directly or indirectly by the United States. (more…)

Fraud-Fighters Being Laid Off

July 1, 2013

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Florida, one of the nation’s hotspots for Medicare and Medicaid fraud, is at particular risk as budget changes in Washington combine to force the layoff this year of 400 employees of the Inspector General’s office at the Department of Health and Human Services.

The Center for Public Integrity reports that the staff-shedding began in January and resulted in 1,200 complaints going without investigation last year. The sequester – automatic across-the-board cuts that went into effect because of Congress’ inability to resolve its internal disputes – is only part of the reason. (more…)

Medicare Urges Seniors to Join the Fight Against Fraud

June 6, 2013

In mailboxes across the country, people with Medicare will soon see a redesigned statement of their claims for services and benefits that will help them better spot potential fraud, waste and abuse. These newly redesigned Medicare Summary Notices are just one more way the Obama Administration is making the elimination of fraud, waste and abuse in health care a top priority. Because of actions like these and new tools under the Affordable Care Act, the number of suspect providers and suppliers thrown out of the Medicare program has more than doubled in 35 states. (more…)

Medicare Fraud Strike Force Charges 89 Individuals for $223M in False Billing

May 15, 2013

medicare fraudAttorney General Eric Holder and Department of Health and Human Services Secretary Kathleen Sebelius announced today that a nationwide takedown by Medicare Fraud Strike Force operations in eight cities has resulted in charges against 89 individuals, including doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $223 million in false billings. Florida accounted for 34 of the arrests made.

This coordinated takedown was the sixth national Medicare fraud takedown in Strike Force history. In total, almost 600 individuals have been charged in connection with schemes involving almost $2 billion in fraudulent billings in these national takedown operations alone. The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country. (more…)

Miami HHA Patient Recruiter Sentenced to 37 Months $20 Million Fraud Scheme

May 7, 2013

A patient recruiter for a Miami health care company was sentenced today to serve 37 months in prison for his participation in a $20 million Medicare fraud scheme. Manuel Lozano, 65, was sentenced to serve two years of supervised release and ordered to pay $1,851,000 in restitution, jointly and severally with co-conspirators.

In February 2013, Lozano pleaded guilty to one count of conspiracy to receive health care kickbacks. According to court documents, Lozano was a patient recruiter who worked for Serendipity Home Health, a Miami home health care agency that purported to provide home health and therapy services to Medicare beneficiaries. (more…)

HHS Proposal Would Increase Rewards to Seniors for Reporting Fraud

April 24, 2013

Health and Human Services Secretary Kathleen Sebelius today announced a proposed rule that would increase rewards paid to Medicare beneficiaries and others whose tips about suspected fraud lead to the successful recovery of funds to as high as $9.9 million. In addition, a new funding opportunity released this month supports the expansion of Senior Medicare Patrol (SMP) activities to educate Medicare beneficiaries on how to prevent, detect and report Medicare fraud, waste and abuse. (more…)