Heart Full of Fraud

180
Shot of two doctors working together on a digital tablet in a hospital

Medicare fraud is one of the most prevalent types of healthcare fraud, costing the U.S. Government and taxpayers billions of dollars each year. Sadly, many of these cases are carried out by fraudsters who work within the healthcare profession. This is true for a pair of Puerto Rican fraudsters who used the medical companies they owned to defraud Medicare. 

Robert Crespo Zamora and Carmen J. Pagán Domínguez  are a husband and wife duo recently charged with health care fraud, aggravated identity theft, conspiracy to commit health care fraud, obstruction of a criminal investigation related to health care offenses, and mail fraud conspiracy.  (Wow. What a list!) A Federal Grand Jury in the District of Puerto Rico returned two separate indictments against the duo.

Domínguez is the owner and biller for Cardiology Medical Group (CMG) and Cardiology Medical Services (CMS). Zamora is owner and biller for Cardiovascular Prophylaxis & Evolution (CPE). He also worked as a cardiovascular technician at his establishments as well as the ones owned by Domniguez. (You’d think owning your own Medical company would make you successful and wealthy enough, but these fraudsters wanted more.)

The first indictment accuses Zamora and Dominguez of filing at least 1,002 false and fraudulent claims totaling $259,147.71 with Medicare. The claims were for non-invasive cardiovascular studies performed by two cardiologists. However, the non-invasive cardiovascular studies were never provided by the physicians listed on the claims. (No surprise there.)

Dominguez’s companies, CMG and CMS, received approximately $132,312.15 for these fraudulently submitted claims. (I think the cost of the procedure alone would give me a heart attack.)

The second indictment accuses Zamora and Dominguez of filing at least three hundred false and fraudulent non-invasive cardiovascular studies claims to Medicare. (They really applied themselves to thinking of new and diverse ways to scam Medicare.) The fraudulent claims, totaling $439,890, were made between January 2020 and May 2020.

Dominguez and Zamora also purportedly submitted claims for non-invasive cardiovascular testing for Medicare beneficiaries despite the tests not being medically necessary. (I’d say that submitting someone for tests under the guise of there being something wrong is invasive.) The results of the tests were also never interpreted by a cardiologist or licensed health care provider. (Again, no surprise there.) Zamora’s company CPA received approximately $249,272 for the fraudulently submitted claims.

Indictments are not evidence of guilt, but rather outlines of the charges against the defendants. Both Dominguez and Zamora are presumed to be innocent until proven guilty in a court of law.

If found guilty in Puerto Rico, they could both face prison time of up to 10 years for healthcare fraud, conspiracy to commit health care fraud, and mail fraud conspiracy. They could also face up to five years imprisonment for the obstruction of a criminal investigation and a mandatory two-year consecutive term in prison for the aggravated identity theft charge. (Couples who commit crimes together often do time together. Just sayin’.)

Today’s Fraud of the Day comes from a Department of Justice press release, “Husband And Wife Indicted And Arrested For Health Care Fraud,” on September 29, 2020.

SAN JUAN, Puerto Rico – On September 24, 2020, a Federal Grand Jury in the District of Puerto Rico returned two separate indictments charging Robert Crespo Zamora and Carmen J. Pagán Domínguez with health care fraud, aggravated identity theft, conspiracy to commit health care fraud, obstruction of a criminal investigation related to health care offenses, and mail fraud conspiracy, announced W. Stephen Muldrow, U.S. Attorney for the District of Puerto Rico.

The Office of Inspector General for the United States Department of Health and Human Services (HHS-OIG) led the investigation with the collaboration of the United States Postal Inspection Service (USPIS). The indictments were unsealed today upon the arrest of the two defendants by federal law enforcement officers from the HHS-OIG and USPIS.

SHARE
Previous articlePhishing for Elderly Victims
Next articleAn Attorney, Pharmacist, and Sales Representative Walk into a Courtroom
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.