Articles Posted in Medicaid and Medicare Fraud

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Seven Floridians, including four doctors, are among 35 people arrested Friday by the FBI for alleged involvement in a $2.1 billion fraud that charged Medicare for false cancer genomic tests (CGx tests).

According to the U.S. Department of Justice (DOJ), the alleged fraud was perpetrated by defendants in Florida, Georgia, Louisiana and Texas and exploited seniors’ curiosity about genetic medicine by enticing them to get unneeded DNA tests.

Dubbed “Operation Double Helix,” the crackdown targeted telemedicine companies, nine doctors and numerous labs following a joint investigation by the DOJ, the FBI, the U.S. Health & Human Services (HHS) Inspector’s General Office and U.S. attorneys’ offices.

The DOJ said the alleged scheme involved a telemarketer or in-person “recruiter” who would persuade a Medicare enrollee to take a genetic test, assuring them the program would pay full cost.

A doctor “in league with the fraudsters” would then approve the test and collect a kickback from the “recruiter,” the indictment reads.

A lab would run the test, bill Medicare, and share payments with the “recruiter,” according to the DOJ.

Reports indicate that the genetic testing bills submitted to Medicaid ranged from $7,000 to $12,000, with some as high as $33,000. In many cases, he said, the patient never got a report back, or the results provided were incomprehensible.

U.S. attorney’s offices in the Southern and Middle districts of Florida filed charges against defendants while four Florida doctors were indicted by U.S. attorneys in New Jersey. 

The federal government and the state of Florida are serious about finding and punishing those who are involved in health care fraud. Law enforcement uses any means to uncover fraud like task forces and undercover operations. Anyone can be the target of an investigation from an individual doctor to a billing company to an entire hospital system.

Our Florida Medicare Fraud Defense Attorneys at Whittel & Melton have extensive experience defending clients against accusations of fraud and related state and federal crimes. We can help with the defense of anyone in the healthcare industry, including:

  • Doctors, nurses and pharmacists
  • Hospitals, hospital systems and clinics
  • Home health care companies
  • Medical billing and coding companies

Medicare and Medicaid fraud investigations in Florida are often the result of inaccurate claims. These claims may include excessive charges, charges that weren’t authorized, and false charges.The federal government will label these claims as fraudulent billing or reimbursement requests. The most common causes of a Medicare or Medicaid fraud investigation are:

  • Phantom billing – billing for services that were never performed
  • Submitting a claim for unnecessary medical services or medical equipment
  • Submitting a claim for medical supplies, equipment, or services that were never ordered
  • Submitting a claim of certification for medically unnecessary supplies 
  • Submitting a claim of certification for medically unnecessary services, like hospice or home health care
  • Double billing
  • Upcoding
  • Inflating charges
  • Overusing medical equipment or services
  • Providing or accepting kickbacks

Doctors, nurses, health care services, physician-owned entities, nursing homes, registered care providers and facilities, hospitals, clinics, pharmacies, laboratories, DME providers, DNA centers, and cancer centers are the most common targets of a health care fraud investigation. As we have stated before, this list is certainly not all-inclusive and any individual, business, facility, or entity in the healthcare industry can be the subject of health care fraud criminal charges. If a person submits a false claim to a federal health care program, even if they do not realize that the claim will be classified as false, they may end up as the subject of a Medicare or Medicaid fraud investigation.

Criminal penalties for Medicare or Medicaid fraud may include one or more of the following:

  • Hundreds of thousands of dollars in fines
  • Up to 10 years in prison for each count of Medicare or Medicaid fraud
  • Up to 20 years in prison for each count of Medicare or Medicaid fraud that resulted in serious bodily harm
  • Life sentence behind bars if the Medicare or Medicaid fraud results in the death of the patient 

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A federal jury found the owner of a Tampa Bay area medical marketing company guilty on Thursday for his role in a $2.2 million-plus Medicare fraud scheme involving the payment of kickbacks and bribes to medical clinics in Miami in exchange for the referral of DNA swabs that were obtained from Medicare beneficiaries.

Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division, U.S. Attorney Maria Chapa Lopez of the Middle District of Florida, Special Agent in Charge Michael McPherson of the FBI’s Tampa Field Office and Assistant Inspector General Shimon Richmond of the U.S. Department of Health and Human Services Office of the Inspector General’s (HHS-OIG) Miami Regional Office made the announcement.

After a four-day trial, the 49-year-old Land o’ Lakes man and owner of DBL Management LLC was found guilty of one count of conspiracy to pay health care kickbacks and one count of structuring currency transactions to avoid reporting requirements.  

The man is expected to be sentenced Oct. 2 by U.S. District Judge Susan C. Bucklew of the Middle District of Florida, who presided over the trial.

According to the evidence presented at trial, the man was paid by Clinical Laboratory Company A for each DNA swab that he arranged to be referred to the laboratory.  In order to obtain DNA swabs, the man paid cash kickbacks and bribes to medical clinics in Miami in exchange for the referral of DNA swabs that were obtained from Medicare beneficiaries. The man directed the owners of the medical clinics to collect the DNA of all of the patients at the clinics, regardless of medical necessity.

In the first phase of the scheme, from November 2013 to May 2014, the evidence at trial showed that the man paid these cash kickbacks directly.  In the second phase of the scheme, from May 2014 to November 2014, after his arrest on other charges, the man established shell companies, including Healthcare Marketing Florida of Melbourne, and conspired with nominee owners to facilitate the payment of kickbacks, receipt of fraud proceeds, and transfer of unlawfully obtained DNA samples for medically unnecessary testing.  Over the course of the entire conspiracy, Clinical Laboratory Company A submitted more than $2.2 million in genetic testing claims and paid the man a percentage of the Medicare reimbursements that it received.

The evidence at trial showed that, in order to conceal his payment of illegal cash kickbacks, the man would travel to different ATMs and bank branches throughout southern Florida and make separate withdrawals of thousands of dollars in cash in order to avoid the filing of U.S. Department of Treasury “currency transaction reports” for an individual withdrawal of more than $10,000.

The man was previously found guilty by a jury in December 2015 of various health care fraud, money laundering and identity theft charges in a case handled by the Criminal Division’s Fraud Section.  

He is currently serving 14 years in prison.

The state of Florida, along with every other state, is constantly looking for ways to bring in additional revenue and to cut the rapidly growing costs of Medicare and Medicaid programs, which is why they are going to such great lengths to uncover potential Medicaid and Medicare fraud and abuse cases. 

In the majority of cases, Medicare fraud involves using false information to obtain unauthorized benefits, and can take a variety of forms, but it typically involves defrauding the Medicare system through billing for services that were not provided or that were not provided as described. Medicare beneficiaries are sometimes involved in fraud schemes where they split the Medicare or Medicaid funds with another party for care that was not provided.

A number of programs exist at both the state and federal level to uncover and prosecute cases of Medicare fraud by patients, providers, insurers, or owners of a company in the healthcare industry. 

Medicare and Medicaid costs the federal government between $80 and $100 billion each year, so government investigators make it their top priority to constantly be on the lookout for any red flags. The Anti-Kickback Statute (AKS) is one tool that the government uses to prosecute actions of fraud. The AKC makes it a crime to give or receive bribes or kickbacks in exchange for patient referrals. 

The penalties for violating the AKS are very serious. The AKS is a criminal statute, and a conviction equates to a felony. A conviction under the AKS can lead to five years in prison and fines of $25,000 per violation. The government can also seek hefty financial penalties of $50,000 for each violation of the AKS.

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The Justice Department announced charges against 24 people across the U.S., including doctors accused of writing bogus prescriptions for unneeded back, shoulder, wrist and knee braces.

Others charged included owners of call centers, telemedicine firms and medical equipment companies.

The Health and Human Services inspector general’s office said the alleged scam morphed into multiple related schemes, fueled by kickbacks among the parties involved. The FBI, the IRS, and 17 U.S. attorney’s offices took part in the crackdown. Arrests were made Tuesday morning.

Medicare’s anti-fraud unit said it’s taking action against 130 medical equipment companies implicated. They allegedly billed the program a total of $1.7 billion, of which more than $900 million was paid out.

Telemarketers would apparently reach out to seniors offering “free” orthopedic braces, also advertised through television and radio ads. Beneficiaries who expressed interest would be patched through to call centers involved in the alleged scheme. Officials described an “international telemarketing network” with call centers in the Philippines and throughout Latin America.

The call centers would verify seniors’ Medicare coverage and transfer them to telemedicine companies for consultations with doctors.

The doctors would allegedly write prescriptions for orthopedic braces, regardless of whether the patients needed them or not. In some cases several braces were prescribed for the same patient.

The call centers would collect prescriptions and sell them to medical equipment companies, which would ship the braces to beneficiaries and bill Medicare. Medical equipment companies would get $500 to $900 per brace from Medicare and would pay kickbacks of nearly $300 per brace.

The alleged scam was detected last summer, officials said. Complaints from beneficiaries were pouring in to the Medicare fraud hotline, and some consumer news organizations warned seniors.

Officials said it’s one of the biggest frauds the inspector general’s office has seen. Charges were being brought against defendants in California, Florida, New Jersey, Pennsylvania, South Carolina and Texas.

Medicare is a federal health care program that provides insurance benefits to seniors. Nationally, over 50 million people receive Medicare benefits. Due to Medicare fraud increasing in recent years, federal investigators and prosecutors have been on the hunt for anyone suspected of Medicare fraud. Whether it was the result of an intentional plan, an oversight, or the actions of your staff and/or employee, being charged with Medicare fraud can wreak havoc on your life. Medicare fraud is a serious crime that may result in several years in federal prison, along with significant fines and a permanent criminal record.

Being charged with Medicare fraud can be frightening and overwhelming. Federal charges must be handled by a lawyer who has experience in this specific field. Our Florida Medicare Fraud Attorneys at Whittel & Melton have the knowledge and skill you need to bring a powerful defense against the health care fraud charges you face.

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Five Tampa Bay area residents are facing charges due to an alleged  billion-dollar telemedicine scheme.

Starting in 2015, the men and their pharmacy companies are accused of setting up an elaborate scheme that fraudulently solicited insurance coverage information and prescriptions from tens of thousands of consumers across the country, according to a 40-page indictment. They then are accused of using the information to sell pain creams and other similar products.

Doctors apparently approved the prescriptions not knowing that the men and their companies had “massively marked up the prices” of the invalidly prescribed drugs, federal prosecutors said. For instance, several of the pharmacies paid $27 for a lidocaine numbing ointment and billed up to $381, an increase of more than 1,300 percent.

Police allege the men “directed their employees to ‘test bill’ or ‘phish’ for the highest reimbursement items” to ensure the most profit. According to the indictment, “These employees routinely submitted claims … for this purpose, contrary to one of more provider agreements.”

Federal prosecutors believe the alleged scheme bilked $174 million from private health care companies, including Blue Cross Blue Shield. In addition, the five men and their companies allegedly submitted at least $931 million in fraudulent claims.

The five men and their companies face a total of 32 counts. All four men were charged with mail fraud, conspiracy to commit health care fraud and introducing misbranded drugs into interstate commerce. If convicted, they face up to 20 years in prison for each mail fraud charge, up to 10 years for each conspiracy charge and up to three years for the third charge. They and their companies could also be required to forfeit up to $154 million.

Last week, four of the men were released on bond after appearing in a federal courtroom in Tampa’s Middle District of Florida. The indictment was filed in the Eastern District of Tennessee.

The fifth man charged has already pleaded guilty to felony conspiracy for his role in the case, according to a statement from the U.S. Attorney’s Office in Tennessee.

He also pleaded guilty to conspiring to commit wire fraud in a separate case.

While the man faces up to 5 years in prison for each conspiracy charge, helping federal prosecutors with the case against the other men could help reduce his sentence.

At Whittel & Melton, our Tampa Bay area Health Care Fraud Defense Attorneys handle criminal cases in Tampa and throughout the U.S. We represent health care practitioners, including doctors, nurse practitioners, therapists, clinics, hospitals, providers of medical equipment and billing companies facing criminal charges with the federal government, including:

  • Overbilling for services
  • Billing for services or tests not rendered
  • Prescribing unnecessary or additional services in order to bill more
  • Incorrectly reporting diagnoses, treatments or procedures to increase payments
  • Unbundling billed services
  • Using false billing codes
  • Submitting duplicate claims
  • Changing dates, services or names of patients on claims
  • Altering medical records or reports
  • Referral kickbacks or self-referrals

Health care fraud may be investigated by the FBI, the state Attorney General’s office, U.S. Postal Service or the Office of the Inspector General. Regardless of what department your case is being pursued by, we can apply the best possible defense strategy with the hopes of securing the best possible outcome.

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A Clearwater doctor has pleaded guilty to one count of health-care fraud and has agreed to surrender her DEA registration number, her Florida medical license and to a permanent exclusion from Medicare and Medicaid programs, according to the justice department.

The 66-year-old woman violated a Florida law that requires doctors to perform an in-person office visit and examine the patient before prescribing a Schedule II controlled substance, according to the Department of Justice.

The woman owned a pain management clinic on Druid Road East in Clearwater.

From as early as July 2011 through December 2017, she billed Medicare for face-to-face patient visits to prescribe controlled substances like oxycodone, but some of those visits didn’t take place on those dates, according to the Department of Justice. Instead, she filled the prescriptions for patients’ families who came by her office, without examining the patients.

She also submitted at least $51,500 false and fraudulent Medicare claims, according to a department of justice news release.

The case was investigated by the Opioid Fraud and Abuse Detection Unit.

Being a healthcare professional means you are subject to extensive regulations and civil statutes. If you fail to comply with the current health care regulations, you can expect to be the target of a federal prosecution. Our Tampa Bay Medicare Fraud Defense Attorneys at Whittel & Melton can help you fight allegations of health care fraud, including allegations relating to:

  • Medicare fraud
  • Medicaid fraud
  • Billing fraud
  • Kickbacks and Gratuities
  • Bribes
  • Conflicts of interest

Prosecutors also file charges against health care providers who allegedly lie about the number of patients they treat or the types of services they perform. We are ready and able to defend doctors and other healthcare professionals who find themselves wrapped up in such inquiries.

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A Columbus doctor has been indicted as part of the nation’s largest health-care fraud enforcement action by the federal government, according to reports.

The 44-year-old Columbus podiatrist was indicted on June 19 in the Southern District of Florida and charged with one count of conspiracy to defraud the United States and receive health-care kickbacks and three counts of receiving health-care kickbacks.

The man’s charges are part of a broader investigation by the Medicare Fraud Strike Force and includes 601 defendants across 58 federal districts, including 76 doctors, as well as nurses and other licensed medical professionals. They are accused of participating in health-care fraud schemes involving approximately $2 billion in false billings.

According to the man’s indictment, he allegedly received kickback payments from PGRX, a Weston, Fla.-based business that recruited and paid doctors to prescribe compounded medications for TRICARE and private commercial insurance beneficiaries.

During the course of the conspiracy, the man and his co-conspirators allegedly signed false medical director and speaker agreements in order to conceal that PGRX was paying the defendant for writing prescriptions, according to the indictment. As a result of these prescriptions, TRICARE made payments to Atlantic Pharmacy, a pharmacy located in the Southern District of Florida.

Medicare fraud is classified as a felony as well as a federal crime that carries some pretty steep penalties, both criminal and civil. The monetary liabilities can be huge. The possibility of being held accountable for Medicare, Medicaid, Tricare, and other health care fraud means you need to be proactive in your defense strategy and seek expert legal help right away. You could be branded a criminal and lose everything you have worked so hard to create in your career as a medical professional.

Regardless of how organized your practice and its operations are, the chances of being audited by Medicare are quite real, especially if you have a successful practice and submit high volume claims to the Centers for Medicare and Medicaid Services (CMS). Keep this in mind: according to government statistics, claims of approximately $50 billion per year are considered suspicious and subject to Medicare fraud investigation.

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A physician and two nurses have been convicted of health care fraud in what authorities claim was a $12 million plus Medicare billing scam.

On Friday, a federal jury in Dallas convicted a 70-year-old doctor and a 47-year-old nurse of conspiracy to commit health care fraud. Both were also convicted of three counts of health care fraud.

Another nurse, 42, was convicted of four counts of health care fraud.

Prosecutors believe the scheme ran from 2007 through 2015. The trio was convicted of defrauding Medicare through false claims through a home health agency and a physician house call company. Evidence showed medically unnecessary home health services were ordered and often not provided.

Sentencing is pending.

The government is aggressively cracking down on Medicare fraud throughout the country like never before. These cases usually mean the government has been investigating a clinic, doctor or facility for months, maybe even years. The government performs a hard investigation into patients’ procedures and billing to find any errors. At Whittel & Melton, our Medicare Fraud Defense Attorneys are here to protect you from the consequences of a conviction. We will help you fight Medicare fraud charges head on.

The most common types of Medicare fraud charges include:

  • False invoicing
  • Improper coding
  • Billing for medical services not provided to the patient
  • Charging for unbundled services
  • Charging for medical devices not provided
  • Billing for patients that do not exist
  • Multiple billings of the same procedure

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A Fort Myers doctor has apparently admitted to defrauding taxpayer-supported Medicare and Tricare by receiving kickbacks for prescribing certain durable medical equipment and pain medications.

The doctor pleaded guilty in federal court Friday to taking more than $470,000 in illegal payments from the supplies and pharmacy businesses between 2010 and 2016, court documents show.

Investigators say the physician paid medical supplier A&G Spinal Solutions $50,000 to put his wife on their payroll and give her 10 percent of the profit stemming from equipment referrals he made to them.

According to related court documents, two co-conspirators and managing partners in the supply business needed the money to pay a tax bill of that same amount. Both have pleaded guilty to their roles in the scheme.

The physician also put together a similar arrangement with an unnamed co-conspirator to receive a share of prescription sales, according to reports.

Finally, between 2013 and 2015, the doctor allegedly received kickbacks from sales representatives and other employees to receive fees for his participation in “largely bogus” speaker event programs, the plea agreement states.

Medicare fraud charges are not uncommon in today’s times. Thousands of unsuspecting and innocent health care providers are forced to defend their actions or face serious criminal consequences every day. Many of these investigations are the result of unfair and overzealous state and federal officials. These federal agents and regulators, who specialize in health care fraud, will raid a practice and demand health care records, computers, etc. and then tell the doctors they are basically out of business. The important thing to understand is that you must assert your rights.

The best reaction you can have is to call an attorney that is skilled in health care fraud. Our Florida Medicare Fraud Defense Attorneys specialize in health care fraud and can establish a strong defense against these allegations. We understand that healthcare providers are dedicated to their line of work and deserve the most powerful defense when their integrity and actions are called into question.

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A chain of podiatry clinics in St. Louis settled with the federal government for $125,000 for Medicare fraud on false claims from 2010 to 2016.

The clinics apparently knowingly billed Medicare for medically necessary toenail removals, when the services provided were routine nail clippings that are not covered by the government insurance program for people older than 65 and others with disabilities, according to the U.S. Department of Justice.

The president of the company issued the following statement:

After becoming aware almost five years ago of some billing errors, we successfully worked with the government to correct this. At all times we have been, and remain in good standing with Medicare. We appreciate that the government worked constructively and cooperatively with us to resolve this matter.

The podiatry clinic has six locations in the St. Louis area: Brentwood/Clayton, Chesterfield, Creve Coeur, Shrewsbury, St. Peters and Ballwin/Valley Park.

Under the settlement, the clinic will repay the government $125,000 for the false claims. The company also signed a three-year agreement with the government for extra oversight in its compliance with Medicare regulations.

The U.S. attorney’s office for the Eastern District of Missouri announced the settlement on Monday.

Toenail care for older Americans is a common source of Medicare fraud. About one-fourth of the podiatry services paid out by Medicare are for nail debridement (removal of a diseased toenail), according to a 2002 report from the U.S. Department of Health and Human Services’ Office of Inspector General.

The investigation found that nearly one-fourth of the nail debridements paid out by Medicare were not justified medically, for an estimated $51.2 million in inappropriate payments in 2000. An additional $45.6 million was paid out in unnecessary related services, according to the report.

Medicare fraud is a very serious charge that carries very real civil and criminal consequences, including stiff monetary fines and the possibility for jail time. If you are a Florida doctor, medical clinic, hospital, or even a recipient of Medicare benefits, and you have been accused of Medicare fraud, you need representation from an experienced and and qualified Medicare Fraud Defense Attorney at Whittel & Melton who is familiar with these types of cases.

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The Department of Justice recently announced that a Las Vegas medical practice will pay $1.5 million to settle allegations that they violated the False Claims Act through illegal billing.

The settlement involved allegations that from January 1, 2006 through May 31, 2011, the practice violated the False Claims Act by billing federal healthcare programs, including Medicare and the U.S. Department of Veterans Affairs, for surgical services that were never actually rendered to its cardiac patients.

The allegations further state that the practice billed for more expensive surgical, evaluation and management services than were provided.

No liability has been determined in this case.

The second case comes from suburban Illinois where a physician has been indicted on federal fraud charges for allegedly receiving almost $1 million in Medicare and private insurer payments for services that apparently never happened.

The physician is the subject of a 12-count indictment alleging that he submitted fraudulent claims for medical tests and examinations that were never performed, as well as used some patients’ names without their knowledge to submit fraudulent claims, according to the DOJ. The indictment claims that from 2008 to 2013, the physician fraudulently obtained, or caused his clinic to obtain, at least $950,000 in payments from Medicare and Blue Cross and Blue Shield of Illinois.

The man is charged with seven counts of healthcare fraud, three counts of making false statements in relation to a healthcare matter, and two counts of aggravated identity theft.  

Health care providers and institutions have a wide range of rules and guidelines they must abide by. Many people forget that these facilities are businesses and must operate as so while providing medical care to patients. Because of ever changing criminal laws and extensive regulations and civil statutes, we have seen an upward rise of doctors, hospitals and medical professionals subject to allegations of health care fraud in the recent years.

Prosecutors actively pursue health care providers who allegedly lie about the number of patients they treat or the types of services they perform, as well as for referring patients to a facility in which the physicians have a hidden financial interest. On that same note, a doctor who receives payment from a company whose medical products they use could potentially face federal prosecution if the payment is used as a kickback or bribe to keep the doctor using the product in question. Medical device distributors and manufacturers can also find themselves under fire for healthcare fraud in these situations. The reality is that there are a plethora of potential pitfalls that plague health care workers and providers on a daily basis.

If you have found yourself ensnared in a federal health care or Medicare fraud investigation, let our Florida Medicare Fraud Defense Attorneys at Whittel & Melton guide you through what to expect. We handle civil and criminal health care fraud matters throughout the state of Florida.

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