The Worst of Intentions

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34631372 - closeup of a medicare enrollment form with money

During 2017, the federal government won or negotiated more than $2.4 billion in healthcare fraud judgements and settlements. (Of that amount $1.4 billion was returned to Medicare, while Medicaid received about $406.7 million.) The Medicare Strike Force, a joint initiative between the Department of Justice and the Department of Health and Human Services, was instrumental in taking down today’s criminals from Miami, Florida. Their contribution to the $2.4 billion Medicare fraud loss tally involved participating in a conspiracy to steal $74 million from the government healthcare benefits program.

Our three criminals include the owner and operator of two defunct Miami home healthcare agencies and two female co-conspirators. For more than six years, the owner and two employees agreed to operate the home healthcare companies for the purpose of fraudulently billing the Medicare program for home healthcare services such as diabetic injections, skilled nursing visit, physical therapy and other treatments and services that were not medically necessary and/or not provided. (That is pretty much the common pattern you see in home healthcare services fraud.)

The 59-year-old owner of the two companies from Miami pleaded guilty to one count of conspiracy to commit healthcare fraud and was sentenced to 80 months in prison. (The judge determined that she was responsible for an intended loss of $74 million.) She must pay $45 million in restitution and forfeiting gross proceeds traced to the offense. (That means she must hand over any cash or items purchased with funds from the crime.)

One of the co-conspirators, who was the administrator of one home health company and an employee of the other company, had the primary role of paying kickbacks and bribes to patient recruiters. In exchange for cash, the patient recruiters provided patients, prescriptions, plans of care and certifications for medically unnecessary therapy and home health services for Medicare beneficiaries. (She kept the pipeline full of victims even though she knew what she was doing was in violation of federal criminal laws.) The 69-year-old Floridian pleaded guilty to healthcare fraud, was sentenced to 60 months in prison and ordered to pay $27 million in restitution.

Further research shows that the other co-conspirator was a co-owner of one of the companies and the administrator of the other one. She also pleaded guilty to healthcare fraud, was sentenced to 80 months in prison and ordered to pay $45 million in restitution.

Sometimes, Medicare providers start out with the best intentions of serving patients to the best of their ability, then somehow get wrapped up in a fraud scheme they originally did not intend. Today’s criminals had the worst of intentions. Their deep-seated greed drove them to steal from vulnerable Medicare beneficiaries. Fortunately, the Medicare Strike Force had the government’s best intentions in mind when they shut down these two fraudulent home healthcare companies and locked the perpetrators away.

Today’s “Fraud of the Day” is based on a Department of Justice press release entitled, Owner of Two Miami Home Health Agencies Sentenced to More Than Six Years in Prison for Role in $74 Million Medicare Fraud Conspiracy,” released on November 21, 2017.

The owner and operator of two defunct Miami home health agencies was sentenced today to 80 months in prison for her role in a $74 million conspiracy to defraud the Medicare program.

Acting Assistant Attorney General Kenneth A. Blanco of the Justice Department’s Criminal Division, Acting U.S. Attorney Benjamin G. Greenberg of the Southern District of Florida, Special Agent in Charge George L. Piro of the FBI’s Miami Field Office, and Special Agent in Charge Shimon R. Richmond of the U.S. Department of Health and Human Services Office of Inspector General’s (HHS-OIG) Miami Regional 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.