Restraining Fraud

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Home health care is necessary for many patients being discharged from hospitals. Just to name a few benefits, it can help patients recover from surgery, obtain a treatment plan to manage diabetes, or receive physical or occupational therapy. (While the additional medical care provides valuable services, it also is a prime target for fraudsters. Because the medical charting is completed within the patient’s home, it is hard to prove that the services performed actually happened or were truly necessary.) A Federal Bureau of Investigation press release details how a man stole more than $20 million from Medicare over five years through two Chicago-based home health companies that he controlled.

The press release states that the man obtained the personal information of hundreds of Medicare beneficiaries and then used the data to enroll them as patients of the two home health care businesses he operated. He directed his staff to alter patient records, sign doctors’ orders supporting fraudulent Medicare claims, pay doctors and others for referrals and divert funds from the scheme to him through various people and shell companies. (He also directed employees to misdiagnose patients with medical conditions they did not have and bill Medicare for treatment that was not necessary.)

Further research reveals that the two clinics submitted more than 14,000 claims to Medicare and received more than $38 million in reimbursements from the government benefits program. (Apparently, this amount classified the two businesses as one of Illinois’ largest recipients of Medicare payments for home health services. This fact no doubt alerted agency investigators.)

The man was sentenced to 10 years in prison for conspiracy to commit health care fraud and tax evasion. He also was ordered to pay $23.3 million in restitution to Medicare and $1.5 million to the Internal Revenue Service. (That’s a pretty stiff sentence. Way to go Judge.)

Fraudsters commonly falsify documents to receive illegal Medicare payments in the home health care industry. While it may be difficult to completely eliminate the crime, this case is proof that the government is working hard at restraining this type of crime, so that thousands of Americans who truly need home health care can actually receive it.

Source: Today’s ”Fraud of the Day” is based on a press release titled, ”Leader of a $23 Million Medicare Fraud Conspiracy Sentenced to 10 Years in Prison,” issued by the Chicago Division of the Federal Bureau of Investigation on April 17, 2015.

CHICAGO—A Chicago man was sentenced today to a 120 month term of imprisonment for taking control of two Chicago-area home health companies and using them to bilk Medicare out of more than $20 million. JACINTO ”JOHN” GABRIEL, JR., 48, has been in custody since February 2014, when he entered a guilty plea to charges of conspiracy to commit health care fraud and tax evasion.

In sentencing Gabriel, U.S. District Judge Charles Norgle ordered him to pay $23.3 million in restitution to the Medicare program and $1.5 million to the Internal Revenue Service.

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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.