91 charged in $430 million billing fraud

ST. PAUL, Minn., Oct. 4, 2012—As reported by Chuck Buck, publisher of the RACmonitor, a sweep of seven U.S. cities by the Medicare Fraud Strike Force has resulted in 91 health-care providers being charged for their alleged participation in Medicare fraud schemes involving approximately $429.2 million in false billing. Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius, along with Inspector General Daniel R. Levinson of the HHS Office of Inspector General (HHS-OIG), among others, made the announcement Thursday, Oct. 4, 2012.

According to an OIG news release, dozens of individuals were arrested or surrendered as indictments were unsealed across the country. The indictments charge more than $230 million in home health-care fraud; more than $100 million in mental health-care fraud and more than $49 million in ambulance transportation fraud and millions more in other frauds.

Following a data-driven analysis, and based upon credible allegations of fraud, HHS also suspended or took other administrative action against 30 health-care providers. Provisions of the Affordable Care Act allow HHS to suspend payments until there has been the resolution of an investigation.

The OIG said more than 500 law enforcement agents from the FBI, HHS-OIG, multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies participated in the takedown which resulted in defendants being charged and accused of various health-care fraud-related crimes, including conspiracy to commit health-care fraud, health-care fraud, violations of the anti-kickback statutes and money laundering.

According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and often never provided. The charges, according to the OIG, were based on a variety of alleged fraud schemes involving various medical treatments and services such as home health care, mental health services, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and ambulance services.

In many cases, court documents allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could submit fraudulent billing to Medicare for services that were medically unnecessary or never provided. Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of conspiring to submit a total of approximately $429.2 million in fraudulent billing. Here are results of the nationwide sweep, according to the OIG.

Miami

In Miami, a total of 33 defendants are charged for their alleged participation in various fraud schemes involving a total of $204.5 million in false billings for home health care, mental health services, occupational and physical therapy and DME. In one case three defendants are charged for participating in a fraud scheme at LTC Professional Consultants and Professional Home Care Solutions, Inc., which led to approximately $74 million in fraudulent billing for home health care. In another case, five defendants are charged for participating in a fraud scheme at Hollywood Pavilion, leading to $67 million in fraudulent billing for mental health services.

Los Angeles

Sixteen individuals, including three doctors and one licensed physical therapist, are charged in Los Angeles with participating in various fraud schemes involving a total of $53.8 million in false billings. In one case, four defendants are charged for allegedly participating in a fraud scheme at Alpha Ambulance, Inc., which led to approximately $49.2 million in fraudulent billing for ambulance transportation. The case represents the largest ambulance fraud scheme ever prosecuted by the Medicare Fraud Strike Force. According to court documents, the defendants provided beneficiaries ambulance rides that were medically unnecessary.

Dallas

In Dallas, 14 individuals, including two doctors and two registered nurses, are charged for their alleged participation in various fraud schemes involving a total of $103.3 million in false billings. In one case, three defendants—a medical doctor and two registered nurses—are charged with participating in a fraud scheme at Raphem Medical Practice and PTM Healthcare Services which led to approximately $100 million in fraudulent billing for home healthcare services.

According to court documents, Dr. Joseph Megwa signed approximately 33,000 prescriptions for more than 2,000 unique Medicare beneficiaries from 2006 to 2011. Many of these Medicare beneficiaries had primary care physicians who never certified home health care services for them. In order to handle the volume of prescriptions, Megwa allegedly signed stacks of documents without reviewing them.

Houston

Seven individuals are charged in Houston for their participation in a fraud scheme at a hospital that led to $158 million in fraudulent billing for community mental health center services. According to court documents, the defendants who served as administrators at the hospital paid kickbacks—in the form of cigarettes, food and coupons redeemable for items available at the hospital’s “country stores”—to Medicare beneficiaries in exchange for those beneficiaries’ attendance at the hospital’s partial hospitalization programs (PHP).

Allegedly, beneficiaries watched television, played games and engaged in other non-PHP activities rather than receiving the services for which the hospital billed Medicare. Previously, on Feb. 22, 2012, the assistant administrator of the hospital, Mohammad Kahn, pleaded guilty to conspiracy to commit healthcare fraud and paying kickbacks related to $116 million worth of fraudulent claims submitted to Medicare. After his guilty plea, an additional $42 million in fraudulent claims were discovered that are included in yesterday’s totals.

Brooklyn

In Brooklyn, 15 individuals, including one doctor and four chiropractors, are charged for their alleged participation in various fraud schemes involving a total of $23.2 million in false billings. In one case, nine defendants, including a medical doctor, are charged with participating in a fraud scheme at Cropsey Medical Care PLLC which led to approximately $13.8 million in fraudulent billing for physical therapy and related services. According to court documents, the defendants paid cash kickbacks to Medicare beneficiaries in exchange for physical therapy that was not medically necessary and on some occasions never provided to beneficiaries.

Baton Rouge

In Baton Rouge, four defendants, including a licensed practical nurse, are charged for their roles in fraud schemes involving approximately $2.4 million in false claims for medically unnecessary durable medical equipment.

Chicago

In Chicago, two defendants, including a dermatologist and a psychologist, are charged for their roles in fraud schemes involving, according to court documents, millions of dollars in false claims for medically unnecessary laser treatments and psychotherapy services.

The charges and allegations contained in the indictments are merely accusations and the defendants are presumed innocent unless and until proven guilty. Learn more at oig.hhs.gov.