Flat Tire

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The Transportation Research Board (TRB) estimates that 3.6 million Americans do not obtain medical care on an annual basis due to a lack of transportation. (Without non-emergency medical transportation, medical costs can skyrocket simply due to a lack of access to preventative care.) The owner of a medical transport company located in Farmington, New Mexico and his primary claims processor took advantage of the desperately needed service to commit healthcare fraud. Together, they fraudulently billed Arizona Medicaid recipients for services that were never provided.

A 33-year-old man from Farmington, New Mexico and a 48-year-old woman from Kirtland, New Mexico created and operated the medical transport company that provided non-emergency medical transportation to Arizona Medicaid recipients. Over two years, the company submitted 18,765 claims for reimbursement to the Arizona Health Care Cost Containment System (AHCCCS), the state’s Medicaid program. (As a result of the mostly false claims, the company collected more than $1.9 million in undeserved Medicaid reimbursements.)

 The company owner made financial transactions involving the proceeds from the Medicaid fraud scheme in a way that he avoided filing Currency Transaction Reports (CTRs). When more than $10,000 in transactions are conducted during any business day, financial institutions must file a CTR. (Law enforcement uses these reports to investigate illegal activities, including money laundering.) For more than two years, the owner made at least 200 cash withdrawals totaling about $800,000. (While each of the transactions was for thousands of dollars, they were for less than $10,000 each so he could fly under law enforcement’s radar.)

As the company’s primary claims processor, the woman pleaded guilty to healthcare fraud for submitting 18,765 fraudulent claims for reimbursement. (This caused the AHCCCS to pay the company a total of $1,959,405.) She was sentenced to 25 months in prison plus three years of supervised release, during which she will have to perform 40 hours of community service each year. The company owner also pleaded guilty to healthcare fraud  and was sentenced to 30 months in prison and three years of supervised release. Both will jointly pay restitution of $1,218,165.

Non-emergency medical transportation is inexpensive when compared to the high cost of healthcare. (Basically, it’s less expensive to transport an individual to preventive care rather than wait for a serious issue to arise. Missed medical appointments are avoided, the impact of chronic disease is lessened, and inpatient costs and healthcare funding can be reduced.) However, fraud like today’s two co-defendants committed, can increase healthcare costs for American taxpayers. Congratulations to the law enforcement agencies involved with taking the air out of this fraudulent scheme’s tires.

Today’s “Fraud of the Day” is based on an article entitled, NM woman gets prison for $1.9MIL health care fraud,” published by Albuquerque Journal on November 8, 2017.

ALBUQUERQUE, N.M. — Rosita Toledo, 48, of Kirtland was sentenced to two years and a month in prison Wednesday in federal court in Albuquerque for her role in a $1.9 million healthcare fraud.

She also was ordered to pay, jointly with her co-defendant, $1,218,165 in restitution, the U.S. Attorney’s Office said in a news release.

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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.