Personal Referrals

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Personal referrals are important when looking for a doctor. (It’s pretty common to poll friends and relatives for physician recommendations. After all, you definitely want the best doctor to treat your particular medical condition.) Medical providers are also searching for referrals to increase their client base and generate a consistent income stream. An article in The Monitor tells the story of a health care marketer who conspired to bilk Medicare of more than $260,000 by paying kickbacks to a co-conspirator in exchange for qualified Medicare beneficiary information. (As you might guess, when an unscrupulous medical service provider pays kickbacks for Medicare referrals, what might seem like a practical business strategy to a fraudster can become legally problematic.)

The story states that the woman issued 11 kickback checks to a co-conspirator in exchange for personal information on qualified Medicare patients. She then took that data and created false referral forms that were subsequently submitted to several home health care companies where she was employed. (The patients never received the services documented on the claims submitted for reimbursement because they were never provided.)

The 51-year-old former home health care marketer, who admitted to forging physician signatures and receiving compensation for her illegal activities, pleaded guilty to conspiracy to commit health care fraud. She received a sentence of two years in federal prison and is required to pay $267,918.61 in restitution. Her co-conspirator was sentenced to six months of home confinement and three years of probation.

While personal referrals can be good for business, they can also have a negative impact on a company’s bottom line if customers are not happy. Instead of using her skills for legal business development, she opted to take a criminal path that impacted the viability of several home health care companies and the funds available for those who deserved to receive the benefits in the first place. (This case just goes to show that if your company needs to raise revenues, defrauding the government s definitely the wrong way to go about doing so.)

Source: Today’s ”Fraud of the Day” is based on an article titled, ”Pharr woman sentenced for health care fraud scheme,” written by Staff and published by The McAllen Monitor on Nov 9, 2015.

A Pharr woman has been sentenced for her role in a scheme to defraud the Medicare program, according to a news release from the Department of Justice.

Martha Lidia Flores, 51, pled guilty to conspiring to commit health care fraud Aug. 28, 2015. The statement said she has been sentenced to two years in federal prison and must pay $267,981.16 in restitution.

According to the statement, Flores issued 11 illegal kickback checks to co-conspirator Argentina Cavazos, 57, of Hidalgo, in exchange for referrals of Medicare beneficiaries from Nov. 15, 2010, to July 9, 2012. Cavazos previously pleaded guilty to her role in the scheme and was sentenced to six months of home confinement and three years of probation, the statement said.

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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.