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Home Health Agencies (HHAs) |
The owner and
Chief Executive Officer of Georgia's largest home health agency,
who pled guilty to charging Medicare and Medicaid for campaign
contributions, ghost employees, and personal vacation trips,
was sentenced to 33 months incarceration followed by three years
supervised work release, during which time she is to perform
200 hours of community service. She was fined $25 million and
ordered to pay $11.5 million in restitution. The company's former
Vice President was sentenced to 151 months incarceration and
three years probation, fined $75,000 and ordered to repay $710,100.
He was convicted of making false statements about salaries for
ghost employees and a related organization, converting workers'
compensation premiums to his own use, using Medicare funds to
support a consulting business, embezzling employee health insurance
and benefit plan funds, committing bank fraud, and laundering
money. In addition, the former agency risk manager was sentenced
to 97 months incarceration and three years probation and ordered
to repay $710,000 after being convicted of mail fraud and conspiracy
to defraud the Medicare and Medicaid programs. The consulting
business of which the risk manager had been president was sentenced
to five years probation, fined $250,000 and ordered to pay restitution
of $710,000. This case is an excellent example of a successful
joint audit and investigative effort.
The owner of
two Pennsylvania HHAs was sentenced to two years probation, assessed
$50, and ordered to perform 100 hours of community service. She
submitted Medicare reimbursement claims for personal expenses,
such as placing her husband and nanny on the company's payroll,
and for non-Medicare expenses such as hotel stays, meals, flowers,
and clothing. Due to her financial situation, she will not be
prosecuted in civil court. However, on the basis of a Medicare
carrier review, $300,000 was withheld and will be retained by
the Medicare program.
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A former nursing
home owner and operator was sentenced in California for filing
over 7,000 fraudulent Medicare claims. He was sentenced to 11
years and three months imprisonment and ordered to pay fines,
restitution, and special assessments of more than $3.5 million.
A joint audit and investigation revealed that the nursing home
owner had billed Medicare for nonexistent medical supplies for
his nursing home, and filed cost reports with false expenses.
He attempted to conceal the scheme by submitting false cost reports
to Medicare, supported by falsified medical records and fabricated
invoices. Two of his employees and two former Medicare carrier
employees who testified against him pled guilty and were sentenced
prior to his trial.
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An Illinois physician
was sentenced to 24 months in prison and ordered to pay a $25,000
fine and $41,460 in restitution for defrauding Medicare and private
insurers. Unable to recruit physicians and sufficient referrals
for a multi-million dollar diagnostic clinic he had built, the
physician billed every patient who visited the clinic $4,000
to $6,000 in unnecessary tests. He entered false symptoms
in the patients' records to justify the billings. The case
involved the difficult issue of proving lack of medical necessity.
The sentencing culminated a lengthy investigation and a five-month
trial, the longest in the southern district of Illinois.
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In Pennsylvania,
a pharmacist was sentenced to eight months imprisonment for defrauding
Medicaid and Medicare. The pharmacist routinely billed
Medicaid for brand name drugs while supplying generic brands.
He also was a partner in a durable medical equipment (DME)
company, which paid kickbacks to his brother for referrals.
The pharmacist was ordered to pay restitution and assessment
of $167,200, and the holding company for his pharmacy had to
pay a $600 assessment. The company's owner and two employees
were sentenced earlier for fabricating test results and forging
physician signatures for equipment. The pharmacist's brother
is to be sentenced in November.
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Durable Medical Equipment (DME) Companies |
A New York jury
returned a guilty verdict against two brothers for conspiracy
related to fraudulent Medicare claims. The two visited
senior citizen high rises, and conducted health fairs where they
coaxed beneficiaries into giving them their Medicare health insurance
numbers. The brothers furnished these numbers, along with
forged certificates of medical necessity (CMNs), to two DME companies.
The companies then billed for equipment, much of which was never
supplied, causing Medicare to pay more than $750,000. The
brothers were paid "commissions" depending on the cost
of each piece of equipment. The two had formerly worked
for two other New York DME companies which were convicted and
sentenced earlier as a result of Office of Inspector General
investigations.
A DME company
in Texas was sentenced to one year of probation for filing false
Medicaid claims for services not rendered. As part of the
plea agreement the company was also ordered to pay restitution
of $450,000. The DME company supplied wheel chair pads
to nursing home patients and then fraudulently billed Medicare
under the code for a lumbar sacral support system, also known
as a "body jacket." Earlier, the former owner
of the DME company pled guilty to mail fraud.
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A North Dakota
state social worker signed an agreement to repay $110,500 she
had defrauded in false Medicaid claims in Minnesota and South
Dakota from 1988 to 1992. She also agreed to a five-year
exclusion from Medicare and Medicaid. The social worker
billed for the services of a physician psychiatrist which were
actually performed by social workers. She conspired with
a psychiatrist who signed the claims, although he performed no
services, in exchange for a part of the reimbursements. The psychiatrist
agreed to pay $80,000 for his part in the scheme.
In Tennessee,
two men were sentenced to seven months incarceration, seven months
home confinement, and two years supervised release for defrauding
Medicaid. The father of one of the men was sentenced to
one day incarceration and 18 months supervised release.
The three submitted fraudulent crossover claims to Medicaid,
including false expenses on cost reports and failure to report
related parties. Prior to this investigation, the father
was incarcerated in a related case, involving his brother and
several nursing homes.
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