Defining Necessary

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close up of word medicare block letter

Healthcare.gov defines “medically necessary” ashealth care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.” A Nigerian man received a Medicare fraud conviction because he paid kickbacks for fraudulent prescriptions that ordered medically unnecessary durable medical equipment (DME).

The Nigerian man, who co-operated a DME medical supply company, and his co-conspirators paid doctors and patient recruiters for prescriptions for DME including power wheelchairs, even though the Medicare beneficiaries did not have a legitimate need for the equipment. Altogether, the man caused the company to submit approximately $8.3 million in claims to Medicare, which allowed the company to collect more than $3.5 million for the fraudulent bills. In addition, the deceptive man admitted he caused $2,090,434 of false claims for medically unnecessary DME to be submitted. (He received $1,076,893 from Medicare for those fraudulent claims.)

The man and a co-conspirator then wrote checks from the company account to company employees and others. The ring leader then instructed the recipients to return the monies to him and pay the illegal cash kickbacks to the patient recruiters and the physicians. (That’s called money laundering.)

The 47-year-old Nigerian man pleaded guilty to healthcare fraud and money laundering. He received a sentence of 46 months in prison and must pay $1,076,893.15 in restitution. A 47-year-old co-conspirator from Carson, California was sentenced to four years in prison and $4,372,466 in restitution, while a 44-year-old co-conspirator from Las Vegas, Nevada was sentenced to 15 months in prison and must pay $3,411,428 in restitution. Both were convicted on charges of healthcare fraud. (You could say that in the end, these three co-conspirators came to an agreement on what medically necessary means. And, the Department of Justice made sure that these three received the necessary punishment for their very unnecessary crimes.)

Today’s “Fraud of the Day” is based on a Department of Justice press release, Nigerian Man Sentenced to Prison for Role in $8.3 Million Medicare Fraud Scheme and Related Money Laundering,” on August 19, 2019.

A Nigerian man was sentenced to 46 months in prison today for his role in a durable medical equipment (DME) scheme in which more than $8 million was fraudulently billed to Medicare for DME that was not medically necessary.

Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division, U.S. Attorney Nicola T. Hanna of the Central District of California, Special Agent in Charge Timothy B. DeFrancesca of the U.S. Department of Health and Human Services Office of Inspector General’s (HHS-OIG) Los Angeles Regional Office, Assistant Director in Charge Paul D. Delacourt of the FBI’s Los Angeles Division and Special Agent in Charge Ryan L. Korner of IRS Criminal Investigation (IRS-CI) Los Angeles Field 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.