Posts Tagged ‘Office of the Inspector General’

Florida Owner of Home Health Care Company Sentenced to Nearly Six Years in Prison for Role in $6 Million Medicare Fraud Scheme

August 29, 2014

HCAF strongly condemns healthcare fraud and supports the removal of bad actors from the home health industry.

A co-owner of Professional Medical Home Health LLC was sentenced today to serve 70 months in prison and ordered to pay $6.2 million in restitution for her participation in a health care fraud scheme involving the now defunct home health care company .

Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida, Special Agent in Charge George L. Piro of the FBI’s Miami Field Office, and Acting Special Agent in Charge Reginald France of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Office of Investigations Miami Office made the announcement. U.S. District Judge Federico A. Moreno of the Southern District of Florida imposed the sentence.

According to court documents, Annarella Garcia, 44, of Hialeah, Florida, was a co-owner of Professional Medical Home Health, a Miami home health care agency that purported to provide home health and therapy services to Medicare beneficiaries. Between December 2008 and February 2014, Garcia and others engaged in a scheme to bill the Medicare Program for expensive physical therapy and home health care services that were not medically necessary or were not provided. During that time, Professional Medical Home Health was paid approximately $6.25 million by Medicare for the fraudulent claims.

Specifically, Garcia and her co-conspirators paid kickbacks and bribes to patient recruiters in return for their providing patients to Professional Medical Home Health for home health and therapy services that were not medically necessary or were not provided. In furtherance of the scheme, Garcia and her co-conspirators falsified patient documentation to make it appear that beneficiaries qualified for and received home health care services, when, in fact, many of the beneficiaries did not actually qualify for such services and did not receive such services.

Garcia pleaded guilty to conspiracy to commit health care fraud on June 25, 2014.

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 is being prosecuted by Trial Attorneys A. Brendan Stewart and 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 nearly 1,900 defendants who have collectively billed the Medicare program for more than $6 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.

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

Source: OIG

Owner Of Home Health Care Company Sentenced To 10 Years In Federal Prison For Role In Health Care Fraud Conspiracy

September 10, 2013

Defendant Also Ordered to Pay More Than $25 Million in Restitution

Cyprian Akamnonu, 64, of Cedar Hill, Texas, was sentenced this morning by U.S. District Judge Sam A. Lindsay to the statutory maximum of 10 years in federal prison and ordered to pay $25,466,779 in restitution, following his guilty plea in October 2012 to one count of conspiracy to commit health care fraud.  Today’s announcement was made by U.S. Attorney Sarah R. Saldaña of the Northern District of Texas.

In handing down the sentence and in response to a plea for leniency, Judge Lindsay stated, “For persons out there who are inclined to commit health care fraud, a low sentence in this case would have no deterrent effect.”  Judge Lindsay also ordered that Akamnonu, who is in custody, forfeit the following property to the government:  four vehicles, 21 parcels of real estate located in Dallas, Cedar Hill and Grand Prairie, Texas and funds in several business and personal bank accounts.

According to documents filed in the case, Akamnonu and his wife/business partner/co-defendant, Patricia Akamnonu, R.N., co-owned Ultimate Care Home Health Services.  Akamnonu admits that from January 2006 through November 2011, he conspired with co-defendants Dr. Jacques Roy and others to defraud Medicare in connection with the delivery of, and payment for, health care benefits, items and services.

A trial date of January 13, 2014, is set for Akamnonu’s co-defendants, Dr. Roy, Patricia Akamnonu, Cynthia Stiger, Wilbert James Veasey, Teri Sivils and Charity Eleda.

According to documents filed in the case, at Akamnonu’s direction, his wife Patricia, and others, recruited Medicare beneficiaries to Ultimate to receive home health care services for which they did not qualify and did not need.   Akamnonu and others would approach people throughout Dallas-area neighborhoods to see if they were qualified Medicare beneficiaries, and if they were, they would attempt to sign them up for home health services.

Once a beneficiary was recruited, Akamnonu would take paperwork to Sivils and other employees of Medistat Group Associates, PA., to be signed on behalf of Dr. Roy, certifying that the Medicare beneficiary was under Dr. Roy’s care, homebound and in need of skilled nursing services, thus allowing Ultimate to bill Medicare for the skilled nursing services.  Akamnonu and Dr. Roy had an agreed-upon, fraudulent arrangement in which Ultimate provided Dr. Roy with the beneficiaries to bolster Medistat’s patient roster in exchange for Roy’s certification for skilled nursing services of any beneficiary sent to him.  In addition, Sivils signed Ultimate’s paperwork on behalf of Dr. Roy because Akamnonu paid her cash kickbacks in exchange for doing so.

At Akamnonu’s direction, nurses would perform cursory visits to the beneficiaries at their homes that bore little relationship to the skilled nursing services for which the beneficiaries had been certified.  Then, at Akamnonu’s direction, Ultimate would bill Medicare for skilled nursing services that were not necessary and were never in fact provided.

During this five-year period, more than 72% of Ultimate’s beneficiaries were certified by Dr. Roy or another Medistat physician acting at his direction.  Ultimate billed more than $40 million to Medicare for skilled nursing services for these beneficiaries and Dr. Roy, in turn, incorporated these patients into his own practice and billed more than $2.3 million for services related to them.

The case is being investigated by the FBI, the U.S. Department of Health and Human Services – Office of Inspector General (HHS-OIG) and the Texas Attorney General’s Medicaid Fraud Control Unit and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division Fraud Section and the U.S. Attorney’s Office for the Northern District of Texas.

Assistant U.S. Attorneys Michael C. Elliott, Mindy Sauter, P. J. Meitl and John DeLaGarza are in charge of the prosecution.

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 HEAT Strike Force, please visit:   www.stopmedicarefraud.gov.

Source: OIG

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OIG Criticizes CMS’ Oversight of Recovery Audit Contractors

September 10, 2013

The Office of Inspection General (OIG) recently issued a report that addresses flaws in CMS’ oversight of recovery audit contractors (RACs). Specifically, the report concluded that RACs are not adequately identifying potentially fraudulent activity and that CMS did not take action to address all referrals of potential fraud that it received from RACs.Additionally, the report found that CMS does not effectively evaluate the corrective actions it puts into place to address identified program vulnerabilities. The OIG was also critical of CMS’ performance evaluations of the RACs  

In FYs 2010 and 2011, RACs reviewed 2.6 million claims and identified approximately 1.3 million claims with improper payments (50 percent) that totaled nearly $1.3 billion. The majority of improper payments were for overpayments related to services delivered in inappropriate facilities or providers billing incorrect codes on claims. The report also noted that a portion of the improper payments were the result of claims submitted for deceased beneficiaries.

The report identified 46 vulnerabilities during the review time period. CMS took corrective action on 28 of the vulnerabilities but had not addressed 18 of them. CMS classifies any specific issue resulting in more than $500,000 in improper payments as a vulnerability and determines which vulnerabilities should be addressed based on several factors – such as improper payment amount and geographic scope.

CMS did not take action to address six referrals of potential fraud in received from RACs. Further, CMS failed to evaluate the effectiveness of the corrective actions it did implement.

The OIG was also critical of CMS’ performance evaluations of the RACs claiming that they did not evaluate the extent to which the RAC identified improper payments. Specifically, there are no metrics in place to measure accuracy, ability, or effectiveness in identifying improper payments.

Two provider types accounted for 93 percent of all recovered or returned improper payments: inpatient hospitals (88 percent) and physicians or non-physician practitioners (5 percent). Although, the large majority of providers did not appeal the denials (94 percent), almost half of the denials that were appealed were overturned. 

The OIG made four recommendations for CMS to take to address the deficiencies identified in the report:

  1. Take action, as appropriate, on vulnerabilities that are pending corrective action and evaluate the effectiveness of implemented corrective actions
  2. Ensure that RACs refer all appropriate cases of potential fraud
  3. Review and take appropriate, timely action on RAC referrals of potential fraud
  4. Develop additional performance evaluation metrics to improve RAC performance and ensure that RACs are evaluated on all contract requirements.

To view the full report, please click here.

Source: NAHC

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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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CMS Imposes First Affordable Care Act Enrollment Moratoria to Combat Fraud

July 26, 2013

Building on strong anti-fraud efforts already underway, Centers for Medicare & Medicaid Services’ Administrator Marilyn Tavenner today announced temporary moratoria on the enrollment of new home health provider and ambulance supplier enrollments in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP) in three fraud “hot spot” areas of the country, including two Florida counties. The goal of the temporary moratoria is to fight fraud and safeguard taxpayer dollars, while ensuring patient access to care. Authority to impose such moratoria was included in the Affordable Care Act, and CMS is exercising this authority for the first time.

Under the moratoria, existing providers and suppliers can continue to deliver and bill for services, but no new provider and supplier applications will be approved in these areas for all three programs. The temporary enrollment moratoria apply to newly-enrolling home health agencies in the Miami and Chicago metropolitan areas; and newly-enrolling ground ambulance suppliers in the Houston metropolitan area (see list of affected counties below). CMS announced the temporary, six-month moratoria in a notice issued today in the Federal Register. (more…)

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…)

Advocates Urge More Government Oversight of Medicaid Managed Care

July 9, 2013

By Jenni Bergal, Kaiser Health News

When the federal government recently gave Florida the green light to vastly expand its experiment with privatizing Medicaid, patient advocates quickly raised an alarm.

They cited serious problems with the state’s five-county pilot managed care program and urged close monitoring of the companies that run private Medicaid plans to ensure that they don’t scrimp on care.

Advocates and experts say that the need for oversight is growing nationally as states have increasingly contracted out the huge state-federal program for the poor to insurance companies, aiming to control costs and improve quality through close management of patient care. About 30 million people are in these plans now. Under the federal health law that launches Jan. 1, eligibility will be expanded and about 7 million more will be covered by Medicaid. Many will be placed in managed care. (more…)

OIG Exclusions & Sanctions Listing Updated for June

June 13, 2013

HCAF has posted the latest exclusion and reinstatements that were released by CMS’ Office of the Investigator General (OIG) on June 11, 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…)