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Medical Billing Fraud

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Page 43 of 52

December 16, 2015

Louisiana doctors Barbara Smith and Roy Berkowitz and registered nurse Beverley Breaux were sentenced to 80 months, 64 months and 50 months in prison, and to pay $9,484,939, $4,952,816 and $2,057,179 in restitution, respectively, for their roles at the center of a $50 million health care fraud scheme.  Specifically, Smith and Berkowitz falsely certified that thousands of Medicare recipients were homebound and required nursing or therapy services to be provided in their homes, and Breaux falsely certified that these patients were homebound and falsely claimed to have treated patients she had not seen.  DOJ

December 7, 2015

The former owner, operator and managers of Southern California ambulance company ProMed Medical Transportation were sentenced to prison for their role in a fraud scheme that resulted in more than $1.5 million in fraudulent claims to Medicare.  Yaroslav Proshak (aka Steven Proshak) was sentenced to serve 108 months in prison.  On December 2, Emilia Zverev and Sharetta Michelle Wallace were sentenced to serve 36 and 24 months, respectively.  In addition, Zverev and Wallace were ordered to pay restitution jointly and severally with Proshak in the amount of $804,755.  The evidence at trial showed that the defendants conspired to bill Medicare for ambulance transportation services for individuals that did not need such services.  The defendants also instructed ProMed EMTs to conceal the patients’ true medical conditions by altering paperwork and creating fraudulent documents to justify the services.  DOJ

December 1, 2015

Wisconsin-based Pharmasan Labs, Inc., its related billing company NeuroScience, Inc. and their founders, Gottfried and Mieke Kellermann, agreed to pay $8.5 million to resolve charges they violated the False Claims Act by (i) submitting false information for laboratory services, and (ii) violating Medicare rules for services referred by non-physician practitioners.  According to the government, and as admitted by Pharmasan under the settlement, Pharmasan falsely billed Medicare for ineligible food sensitivity testing; knew Medicare prohibited payment for such testing; and submitted false information to Medicare to disguise the type of test it was performing so Medicare would cover it.  Pharmasan also admitted violating Medicare billing rules which bar payment for lab services referred by non-physicians.  The government investigation leading to the settlement originated from a whistleblower action filed under the qui tam provisions of the False Claims Act.  The whistleblower will receive a whistleblower award of roughly $1.1 million from the government’s recovery.  Whistleblower Insider

November 19, 2015

Florida-based hospice company Hospice of Citrus County agreed to pay roughly $3 million to settle charges the company violated the False Claims Act by knowingly billing Medicare and Medicaid for medically unnecessary and undocumented hospice services.  The allegations resolved included liability under the False Claims Act.  Specifically, the government alleged the company treated at least 52 patients with lengths of stay in excess of 1,000 days and either knowingly or recklessly failed to document a valid basis for the initial start of hospice care and/or subsequent hospice coverage.  The failure in documentation included no support for the length of hospice services; patient files that failed to document basic patient characteristics; and patient records that were either unsigned or signed with inconsistent practitioner information.  In some cases, patients were admitted to HOCC simply because their spouse was in hospice care.  DOJ (MDFL)

November 18, 2015

Deaconess Home Health, Inc. (formerly known as Outreach Home Health) and its owner, Lazarus Bonilla, agreed to pay $3,724,000 to resolve charges they violated the False Claims Act through the false billing of personal care worker services to the Wisconsin Medicaid Program.  Specifically, the defendants (1) intentionally recruited patients for personal care services without regards to whether the services were medically necessary; (2) instructed nurses employed by Deaconess to routinely inflate, without regard to medical necessity, the assessment of the patient that was provided to the Medicaid program; (3) failed to conduct required supervisory visits to ensure that services were in fact being provided, that services continued to be medically necessary, and that any services provided were appropriate for the needs of the patient; and (4) hired physicians to act as medical directors to sign plans of care for patients on whom they had not completed a physical examination.  The allegations first arose in three whistleblower lawsuits filed under the qui tam provisions of the False Claims Act.  Two of the whistleblowers are former employees of Deaconess.  The whistleblowers collectively will receive a whistleblower award of approximately $600,000.  (DOJ (EDWI)

November 16, 2015

HCA Holdings, Inc. (including affiliated entities Hospital Corporation of America; Parallon Business Solutions, LLC; West Florida Regional Medical Center, Inc.; HCA Health Services of Florida, Inc.; Regional Medical Center Bayonet Point; HCA Health Services of Florida, Inc.; New Port Richey Hospital, Inc.; and Medical Center of Trinity) agreed to pay $2 million to resolve charges of violating the False Claims Act through billing Medicare for unnecessary lab tests and double billing for fetal testing.  The allegations first arose in a whistleblower lawsuit by HCA employee Kelly Oxendine under the qui tam provisions of the False Claims Act.  The whistleblower will receive a whistleblower award of roughly $400,000 from the government’s recovery.  DOJ(SC)

November 13, 2015

Tamara Esponda, owner of Miami-area pharmacy Biomax Pharmacy Inc., was sentenced to 42 months in prison and to pay roughly $1.6 million in restitution for her role in the submission of more than $1.5 million in fraudulent claims to Medicare Part D.  According to admissions made in connection with Esponda’s guilty plea, Biomax Pharmacy submitted fraudulent claims to Medicare for prescription drugs that were not prescribed by physicians, not medically necessary and not provided to Medicare beneficiaries.  Esponda further admitted that in perpetrating this fraud she and her accomplices used the beneficiaries’ and doctors’ Medicare identification numbers without their consent.  DOJ

November 6, 2015

Valery Bogomolny, owner of Royal Medical Supply, was convicted for his role in a $4 million Medicare fraud scheme.  According to evidence presented at trial, Bogomolny used his company to bill Medicare for power wheelchairs, back braces and knee braces that were medically unnecessary, not provided to beneficiaries or both.  The evidence further showed Bogomolny created false documentation to support his false billing claims, including creating fake reports of home assessments that never occurred.  DOJ

November 6, 2015

Roger Rousseau, former medical director of defunct health provider Health Care Solutions Network Inc. (HCSN) was sentenced to 192 months in prison for his role in a scheme to fraudulently bill Medicare and Florida Medicaid more than $63 million.  Also sentenced to prison for their role in the scheme were therapists Liliana Marks for 72 months and Doris Crabtree and Angela Salafia, each for 60 months.  According to evidence presented at trial, HCSN purported to provide intensive mental health services to Medicare and Medicaid beneficiaries but these services were not medically necessary and were often never even provided.  HCSN also paid kickbacks to assisted living facility owners and operators who in exchange referred beneficiaries to HCSN.  In support of this scheme, Rousseau routinely signed what he knew to be fabricated and altered medical records.  And Crabtree, Salafia and Marks fabricated HCSN medical records to support the fraudulent claims.  In total, HCSN submitted roughly $63.7 million in false and fraudulent claims to Medicare.  DOJ

October 30, 2015

The Department of Justice reached 70 settlements involving 457 hospitals in 43 states for more than $250 million related to cardiac devices implanted in Medicare patients in violation of Medicare coverage requirements.  The devices, called implantable cardioverter defibrillators (ICDs), are electronic devices implanted near and connected to the heart to detect and treat chaotic, extremely fast, life-threatening heart rhythms, called fibrillations, by delivering a shock to the heart, restoring the heart’s normal rhythm.  Only patients with certain clinical characteristics and risk factors qualify for an ICD covered by Medicare.  According to the government, from 2003 to 2010 each of the settling hospitals implanted ICDs during periods prohibited by the Medicare’s National Coverage Determination.  Most of the settlements originated from allegations first raised in a whistleblower lawsuit brought under the qui tam provisions of the False Claims Act by Leatrice Ford Richards, a cardiac nurse, and Thomas Schuhmann, a health care reimbursement consultant.  They have so far received a combined whistleblower award of more than $38 million from the settlements.  The Department of Justice is continuing to investigate additional hospitals and health systems.  DOJ
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