Recently in Medicare Fraud Category

Owner of Health Care Clinic Pleads Guilty to $71 Million Medicare Fraud Scam

November 27, 2013, by The McKellar Law Firm, PLLC

After two years on the run from authorities, health care clinic owner Irina Shelikhova has been apprehended and subsequently sentenced for her role in an elaborate Medicare fraud scheme.

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Shelikhova was the owner of a Brooklyn, New York medical clinic. The clinic was billing Medicare under three corporate names: Bay Medical Care PC, SVS Wellcare Medical PLLC, and SZS Medical Care PLLC. All of these entities were known collectively as Bay Medical Clinic. As owner of these clinics, Shelikhova masterminded a scheme from 2005 to 2010 to pay kickbacks to her "patients" in order to bill Medicare approximately $77 million in medical services that were either never provided or unnecessary. According to testimony, the owner went so far as to hire a medically unlicensed person to act as a doctor to provide medical care to her patients. She also directed her staff to make fake notations in patients' medical files and charts to assist with the bogus billing.

In order to facilitate the large amount of cash needed to pay her patients kickbacks, Shelikhova employed a gaggle of money launderers. She would write checks drawn on the medical clinic to several shell companies that were controlled by her network of money launderers. In turn, the launderers would cash the checks and give the cash back to the clinic. Patients were paid $50 or more to allow the clinic to bill Medicare for bogus medical services. From April to June 2010, approximately $500,000 was paid in kickbacks by Shelikhova to patients.

Shelikhova was originally indicted in July 2010. However, she fled the country and hid out in the Ukraine for two years. Upon her return to the U.S., Shelikhova was apprehended at the JFK airport in New York.

Shelikhova plead guilty to one count of conspiracy to commit money laundering. She has been sentenced to serve fifteen years in prison; three years of supervised release with a concurrent exclusion from Medicare, Medicaid, and all other Federal healthcare programs; ordered to forfeit $36,241,545; and ordered to pay $50,943,386 in restitution. Thirteen other co-conspirators have also been convicted in this case; one of those being Shelikhova's son.

Sources
http://www.nydailynews.com/new-york/medicare-fraud-fugitive-nabbed-jfk-airport-article-1.1099421

http://www.fbi.gov/newyork/press-releases/2012/owner-of-brooklyn-clinic-pleads-guilty-in-connection-with-71-million-medicare-fraud-scheme

http://www.justice.gov/opa/pr/2013/November/13-crm-1207.html

Medical Director & Six Therapists Indicted for Alleged $63 Million Health Care Fraud

July 22, 2013, by The McKellar Law Firm, PLLC

Health care fraud attorneys will rarely see larger health fraud cases than the case involving Health Care Solutions Network (HCSN), which resulted in the arrest of 7 people last week in Miami, Florida. HCSN's medical director, Roger Rousseau, and six therapists were arrested for allegedly defrauding Medicare and Florida Medicaid out of more than $63 million.

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According to the indictment, from roughly 2004 through 2011, director Rousseau and therapists Doris Crabtree, Angela Salafia, Liliana Marks, Ruben Busquets, Alina Fonts, and Blanca Ruiz all allegedly took part in committing various health care fraud schemes that included providing health services that were either unnecessary or not given, altering and fabricating medical records, and constructing false and fraudulent claims for services that, again, either unnecessary or not given.

Although the case against these HCSN employees is still currently under investigation, 18 USC § 1347 outlines the possible consequences if they are convicted of having committing health care fraud. Punishments include severe fines and imprisonment of up to 10 years, or both. In the event that serious bodily injury or death resulted as a consequence of the fraud, prison terms increase to 20 years or life, respectively.

The so-called "ringleader" of the HCSN health care fraud scheme, Armando Gonzalez, has already entered a guilty plea for conspiracy to commit health care fraud and money laundering. In February of 2013, he was sentenced to 24 years in federal prison and ordered to pay restitution of in excess of $28 million.

According to the FBI's "White Collar Crime" website, health care fraud is estimated to cost our country $80 billion annually with that figure rising every year. Because the loss is so high and the effects far-reaching, the federal government will continue to prosecute those persons suspected of defrauding either/both federal and private insurance programs.

Tennessee Physical Therapy Assistant Pleads Guilty to Health Care Fraud

September 19, 2012, by The McKellar Law Firm, PLLC

According to 18 USC § 1347, anyone convicted of defrauding, or attempting to defraud, a health care benefit program faces fines and possible incarceration, which could even result in a life sentence if death resulted from the deception. Former physical therapist assistant Patricia J. Boshears of Knoxville, Tennessee recently pled guilty to violating this statute, according to a press release from the U.S. District Attorney's Office.

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The press release states that Boshears formerly owned, managed, and worked as a physical therapy assistant at Total Rehab, Inc. in Knoxville, Tennessee. After an investigation by the Office of Inspector General, Health and Human Services Division, Boshears acknowledged deliberately filing false claims in an attempt defraud Medicare for patient services that did not qualify for reimbursement. In order for claims to qualify for Medicare reimbursement, all patient services must be provided by either a licensed physical therapist or under the direct supervision of a licensed physical therapist. However, from June 2009 to October 2010, Boshears and other Total Rehab, Inc. employees operated unlicensed and without supervision resulting in Medicare incurring losses of $68,096.27.

Boshears now faces a possible 10-year prison sentence as well as financial liability for restitution, forfeiture, and other fines. Her sentencing hearing is scheduled for December 17, 2012 before the Honorable Thomas W. Phillips.

Texas Doctor and Staff Charged in Alleged $375 Million Medicare Scheme

April 3, 2012, by The McKellar Law Firm, PLLC

The Federal Government is continuing its crackdown on Medicare fraud. According to a recent article in the Insurance Journal, a physician, his office manager, and five owners of home health agencies were arrested after allegedly committing health care fraud totaling nearly 375 million dollars in Dallas, Texas.

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These charges come after investigations conducted by the Medicare Fraud Strike Force, a division of the Health Care Fraud Prevention and Enforcement Action Team (HEAT). According to the investigation, Dr. Jacques Roy owned and operated a practice that certified or directed the certification of more than 11,000 individual patients from more than 500 home health agencies (HHA). During its five-year stint, Dr. Roy's practice certified more Medicare beneficiaries for home health services and had more patients than any other medical practice in the United States. According to the indictment, the fraudulent activity caused more than $350 million dollars to be erroneously billed to Medicare and more than 24 million dollars to be fraudulently billed to Medicaid by Dr. Roy and the HHAs associated with his practice.

Dr. Roy and the HHAs with whom he allegedly conspired with were caught due to suspicious billing spikes tracked by the Health and Human Services (HHS). While a vast majority of physicians who certified patients for home health only signed off on 104 or fewer patients in the year 2010, Dr. Roy certified more than 5,000 patients in that year alone.

The federal government has recently been cracking down health care fraud due to its belief that such fraud not only increases costs for consumers, taxpayers, and health insurance plans; it also victimizes the elderly and disadvantaged. Since 2007, the Medicare Fraud Strike Force has charged more than 1,190 defendants who have collectively charged the Medicare program more than 3.6 billion dollars. So to send a clear message to other potential physicians thinking about committing healthcare fraud, Dr. Roy and his fellow conspirators each face up to ten years in prison and a $250,000 fine for each count of conspiracy as well as a maximum penalty of five years in prison and a $25,000 fine for each false statement charged against them. Seventy-eight additional HHAs associated with Dr. Roy have also been suspended by the Centers for Medicare & Medicaid Services (CMS) based on allegations of fraud against them.


Florida Man Sentenced to 50 Years in Federal Prison for Medicare Fraud

October 3, 2011, by The McKellar Law Firm, PLLC

The Miami Herald reports that a Florida man is now facing over 50 years in Federal prison for Medicare fraud while running a chain of mental-health clinics in Florida. This sentence is the longest single sentence handed down for a Medicare fraud conviction.

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Over an eight-year span, Duran collected $87 million in Medicare payments and $205 million in bills that he generated by paying kickbacks to physicians who would refer patients to his clinic, American Therapeutic. He then began to be investigated after a former nurse filed a civil whistle-blower case in 2007 with the Justice Department. The Justice Department contacted American Therapeutic's lawyer about the investigation, yet Duran did not stop committing fraud until he was finally arrested.

While showing remorse for his actions during the sentencing proceedings, Duran admitted that he tried to steal as much money as he could from Medicare. Also, while Duran claimed that he lived a "middle-class life" while committing fraud, he drove a Maserati, sent his three children to private school, and paid for his ex-wife's home in North Miami while traveling out of the country with his girlfriend.

The judge gave an extremely high sentence to send a message that there is a "critical need for deterrence against healthcare fraud" in Florida. As of now, Florida is the nation's capital of Medicare corruption. Both Duran and his girlfriend, who co-owned American Therapeutics with Duran, pled guilty to conspiracy, fraud, and money-laundering. Thirty-four other people, including American Therapeutic employees, doctors, therapists, nurses, and recruiters have also been charged. Prior to Duran's sentencing, the highest Medicare fraud sentence was thirty years back in 2008.

Florida Doctor Convicted for Healthcare Fraud After 3-Week Jury Trial

A Miami-area doctor was convicted in federal court after a jury determined that he was guilty of five felony counts for his role in a $23 million dollar HIV injection and infusion Medicare fraud scheme, according to a press release from the Department of Justice. The federal court jury convicted Rene De Los Rios of one count of conspiracy to commit health care fraud and four counts of submission of false claims to the Medicare program. The conspiracy charge carries a maximum penalty of 10 years in prison and a $250,000 fine, while each false claims count carries a maximum penalty of five years in prison.

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Evidence presented at trial showed that the Dr. De Los Rios was hired by the medical clinic owner, Damaris Oliva, to "order unnecessary tests, sign medical analysis and diagnosis forms, and authorize treatments to make it appear that legitimate medical services, including injection and infusion therapies, were being provided to patients who were Medicare beneficiaries." De Los Rios was also accused of signing patient charts, often without seeing the patient, indicating that injection and infusion treatments were medically necessary, when, in fact, he knew they were not. Further, De Los Rios allegedly diagnosed almost all of his patients with the same rare blood disorders, which the patients did not in fact have, in order to ensure maximum reimbursement from Medicare, and that he prescribed expensive (and medically unnecessary) medications to patients for the sole purpose of receiving reimbursement from the Medicare program.

This case represents another victory for the Medicare Fraud Strike Force, which has now charged more than 1,000 defendants and organizations that collectively have billed the Medicare program for more than $2.3 billion. In this particular case, from approximately April 2003 through October 2005, the medical clinic where De Los Rios worked submitted approximately $23 million in claims to the Medicare program for injection and infusion treatments for Medicare beneficiaries that were not medically necessary, and were not provided. The Medicare program paid approximately $11.7 million in claims.

Florida Doctor Found Not Guilty of Medicare Fraud

March 22, 2011, by The McKellar Law Firm, PLLC

While the majority of this blog is focused on the pitfalls of federal criminal defense for both attorneys and defendants, I enjoy learning about positive outcomes in cases, especially when a jury has decided that a defendant is not guilty. Earlier this month, a federal jury returned a not guilty verdict against Dr. Jorge J. Dieppa, who had been charged with committing Medicare fraud. According to an article in The Miami Herald, Dieppa was accused of sending hundreds of 300 patients to a pair of Miami area home healthcare agencies for costly diabetic services that prosecutors said were unnecessary or not provided.

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Dieppa exercised his right to testify, and he declared that he evaluated all of his patients and relied on his nurses before deciding whether the Medicare beneficiaries were qualified to receive diabetic services at home. Dieppa was originally charged by federal authorities, along with 93 other people with conspiring to defraud $251 million from Medicare by filing allegedly phony claims with the taxpayer-funded healthcare program.

In my experience, having clients testify is a high-risk, high-reward situation. In certain cases, a client's willingness to take the witness stand against the barrage of questioning and allegations from the Government can be well-received by a jury. Conversely, sometimes a client's decision to testify can result in convincing a jury of a client's guilt, even though a client may view him/herself as very persuasive. Ultimately, the decision to testify rests with the client, but it is a decision that should only be made after careful analysis with an experienced criminal defense attorney who may be aware of pitfalls that may be unknown to the client.

Atlanta Doctor Indicted for Healthcare Fraud for Allegedly Treating Dead Patients

March 5, 2011, by The McKellar Law Firm, PLLC

An Atlanta, Georgia doctor has been indicted for filing false Medicare and Medicaid claims for patients which he never saw, including some patients who were already dead at the time he claimed to have administered treatment to them. The Atlanta Journal Constitution reports that Dr. Robert Williams was indicted in Atlanta for healthcare fraud and was arraigned yesterday in federal district court.

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According to a press release from the U.S. Attorney's Office in Atlanta, the prosecution alleges that Dr. Williams, during 2007 to 2009, contracted with a medical services company to provide group psychological therapy to nursing home patients. Per the doctor's signature, thousands of claims were submitted to Medicare and Georgia Medicaid seeking reimbursement for group psychological therapy that Dr. Williams claimed to provide to beneficiaries at nursing homes in the Atlanta area. Allegedly, in many instances, the doctor did not actually provide the therapy claimed.

Doctors are typically held to a high standard of conduct due to their position in society. In the aforementioned press release, prosecution representatives claim:

"As a physician, this defendant had a duty to protect his patients and look out for their interests first. He has been charged with crimes that reflect his misuse of his position and the trust placed in him, all at the expense of his elderly patients, Medicare and Medicaid. Dr. Williams allegedly stole Medicaid funds that were specifically allocated for the care of some of Georgia's most vulnerable citizens: the elderly."

If convicted of these healthcare fraud allegations, Dr. Williams is looking at a maximum 10-year sentence, a fine up to $250,000, and likely restitution of amounts improperly taken.

Doctor Receives Prison Sentence for Lying to FBI

January 12, 2011, by The McKellar Law Firm, PLLC

Federal Criminal Defense Lawyers rarely allow their clients to speak to government agents for a variety of reasons, most of which have to do with protecting clients from themselves. A great example of a person hurting themselves by talking to government agents is the case of Dr. Howard Goldstein.

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Last week, Goldstein was sentenced to 5 months imprisonment, a $30,000.00 fine, and he agreed to an additional $100,000.00 forfeiture for making false statements to an agent of the Federal Bureau of Investigation, in violation of 18 U.S.C. Sec. 1001. In an April 2010 interview with the FBI, Goldstein was questioned about problems with his Medicare billing practices and he "minimized and mis-characterized concerns and problems" that had been raised by his former employer. Goldstein also previously paid $830,329 to the government in a related civil settlement agreement, and has been banned from participating in the Medicare program for five years.

18 U.S.C. Sec. 1001(a) provides:
Except as otherwise provided in this section, whoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States, knowingly and willfully--
(1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact;
(2) makes any materially false, fictitious, or fraudulent statement or representation; or
(3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry;
shall be fined under this title, imprisoned not more than 5 years or, if the offense involves international or domestic terrorism (as defined in section 2331), imprisoned not more than 8 years, or both. If the matter relates to an offense under chapter 109A, 109B, 110, or 117, or section 1591, then the term of imprisonment imposed under this section shall be not more than 8 years.

Some of the best advice I can ever give a client is to simply shut up. Talking to investigators, police, case workers, and other government officials rarely benefits a client's case. To make matters worse, many people choose to talk to government officials without an attorney present. I can only imagine that Dr. Goldstein's case would have worked out differently had he consulted with an attorney prior to an interview with FBI agents.

Additional Resources
18 U.S.C. Section 1001
"Doctor Sentenced For Making False Statements to FBI," St. Louis Globe-Democrat (Online Edition), January 5, 2011

Healthcare Fraud Investigations to Increase Due to Affordable Care Act

October 25, 2010, by The McKellar Law Firm, PLLC

Healthcare fraud attorneys spend much of their time dealing with investigations and pre-charge or pre-indictment activities of violation of 18 U.S.C. Section 1347, which says:

Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice-- (1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both. If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.

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In an article written by Bob Gatty with Modern Medicine, he writes about the statements of Daniel R. Levinson, inspector general at the Department of Health and Human Services, who claims that "the new Affordable Care Act (ACA) provides additional resources and authority designed to crush healthcare fraud schemes that contribute to the skyrocketing cost of healthcare in the United States. Gatty writes that in the last year, the Office of Inspector General has opened more than 1,300 healthcare fraud investigations and obtained more than 500 convictions, resulting in nearly $3 billion in expected civil and criminal recoveries. While these numbers are staggering, those in the medical field should anticipate increased investigation, litigation, and financial and criminal penalties.

Medical providers need to a) be vigilant in complying with all federal regulations, especially those providers who provide Medicare / Medicaid services, and b) employ the services of an experienced healthcare criminal defense lawyer immediately upon receipt of a summons or upon learning of a potential investigation. Oftentimes, clients mistakenly wait until a government investigation is well under way before beginning the process of obtaining a healthcare attorney to prepare his/her defense.