Getting Your Head Examined

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Partial Hospitalization Programs (PHP) diagnose and treat people, who have mental illness or substance abuse issues. These programs are not classified as inpatient or outpatient services, but something in-between. Patients usually live at home but can commute to a hospital or medical treatment center up to seven days a week. A typical day of treatment might include group or individual therapy and psychopharmacological assessments for patients being treated for alcoholism, drug abuse, Alzheimer’s disease, anorexia, bulimia, depression, bipolar, anxiety or a variety of other substance abuse and/or mental illnesses. The Imperial Valley News reports on a story about a Miami-based mental health clinic that billed Medicare for $55 million in fraudulent PHP services that were never provided or required.

The article states that a former therapist and co-conspirators at the mental health clinic, which operated a PHP program, submitted the fraudulent claims to Medicare. The scam involved paying patient recruiters to refer ineligible Medicare beneficiaries to the clinic. According to court documents, some of these ineligible patients were chronic substance abusers and had severe dementia and would not benefit from group therapy. Other patients had no mental health diagnosis and were seeking exemptions for their U.S. citizenship applications.

Court records also state that the former 39-year-old therapist either showed up late or did not show up at all for the sham therapy sessions that he reported to Medicare. He created false documents, including group therapy notes that were duplicated across multiple records to cover up the fraud. Sometimes identical information, including the same misspelled words, was recorded across multiple patient files over several years. (Note to self – don’t record the same information for different patients, and if you do, make sure to use spell check. Someone might get suspicious.) This fraudster was certainly entrepreneurial and offered his co-conspirators a selection of fake group therapy notes for a fee. (He was just trying to make it easy for them.)

The former therapist was convicted of one count of conspiring to commit health care fraud after a one-month jury trial. He will serve 10 years in prison and three years of supervised release. He was also ordered to pay $11 million in restitution, jointly and severally with his co-defendants. The co-defendants included the owners and operators of the clinic, doctors, managers, therapists and patient brokers who were also charged with health care fraud, kickbacks, money laundering plus other offenses. The three owners and operators of the clinic were sentenced to 30 years, 25 years and 22 years in prison. (I like this judge! Go big or go home.) More than 25 of the defendants charged have pleaded guilty or been convicted at trial.

The goal of a PHP program is to rehabilitate the patient, while preventing inpatient hospitalization and reducing the cost of long-term care. Obviously, these fraudsters have done the opposite and cost the government and American taxpayers millions of dollars, driving up the cost of health care in the end. Let’s hope that while in prison, these criminals will participate in an in-prisoner rehabilitation program where they can have all of their heads examined. Perhaps after they serve their sentence, they’ll come out with a new perspective on life and learn from their mistakes.

Source: Today’s ”Fraud of the Day” is based on the article titled, ”Former Mental-Health Clinic Therapist Sentenced for Role in $55 Million Medicare Fraud Scheme,” published in the Imperial Valley News on November 6, 2013.

WASHINGTON, DC – A former therapist for Biscayne Milieu, a Miami-based mental-health clinic, was sentenced today to serve 120 months in prison for his participation in a $55 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) Miami office made the announcement.

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Larry Benson
Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.