Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Policy and Regulation News

Commercial, Public Payer Healthcare Fraud Cases Total $21.6M

A recent string of commercial and public payer healthcare fraud cases totaled $21.6 million from providers participating in false reimbursement and kickback schemes.

Healthcare provider fraud cases totaled $21.6 million in recent months.

Source: Thinkstock

By Thomas Beaton

- The latest string of commercial and public payer healthcare fraud cases totaled $21.6 million from providers launching various schemes such as patient kickback agreements and false claims submissions.

Public payer programs are frequently targeted by criminals and have a high risk of provider fraud. Federal agencies recovered nearly $2.4 billion in 2017 through civil and criminal recoveries involving provider organizations.

Commercial payers are also at risk for healthcare fraud when participating providers see an opportunity to poach significant funds.

Law enforcement agencies including OIG and US District Attorney’s Offices across the country have worked with HHS and Medicare Fraud Control Units to recover millions in ill-gotten provider revenues

BlueCross BlueShield of Miami targeted for $10 million in false claims filings

A Miami health clinic owner was found guilty of submitting nearly $10 million in fraudulent healthcare claims to BlueCross BlueShield (BCBS) of Miami, as well as to public payer programs.

Vladimir Prado Sr. was sentenced to 97 months in prison in Southern District of Florida and will pay over $4 million in restitution fees with his co-conspirators.

Prado pleaded guilty on February 2, 2018 to conspiracy to commit healthcare fraud after submitting an initial $5 million in false and fraudulent claims to BCBS. Prado was able to generate $2.6 million in revenue from the payer.

Prado also owned another clinic and submitted a separate $2 million in claims to BCBS, gaining $1.4 million through BCBS reimbursements. Prado also admitted that the second clinic submitted $2.2 million in false claims to Medicare.

The case was investigated by the FBI, HHS, OIG, and the US Attorney’s Office for the Southern District of Florida.

Michigan-area home health owner found guilty in $8 million Medicare kickback scheme

An owner of a home health facility in Michigan pleaded guilty to his involvement in a scheme that defrauded $8 million from the Medicare program.

Zahir Shah of West Bloomfield, Michigan admitted he paid kickbacks to patient recruiters and then billed Medicare via the illegal patient referrals. Shah submitted claims from 2007 to 2017.

Shah also admitted that he submitted false certifications to stay enrolled as a Medicare provider. Shah was convicted on count of conspiracy to commit healthcare fraud, wire fraud, and conspiracy to pay and receive kickbacks in connection to Medicare beneficiaries.

FBI, OIG, HHS, and US Attorney’s Office for the Eastern District of Michigan led primary investigations for the case.

Texas-based home health patient recruiter convicted in $3.6 million Medicare fraud scheme

A patient recruiter for a Texas-based home health center, Texas Tender Care, was convicted for her role in defrauding Medicare of $3.6 million.

Mercy O. Ainabe of Houston, Texas was convicted in the state’s Southern District Court for one count of conspiracy to commit healthcare fraud, five counts of healthcare fraud, and one count of conspiracy to pay healthcare kickbacks.

Ainabe and co-conspirators submitted claims to Medicare for home health services that were either not medically necessary or not provided to beneficiaries. Ainabe paid providers, beneficiaries, physical therapy organizations, and other entities for paperwork needed to create false claims.

The case was investigated by HHS, OIG, and the US Attorney’s Office for the Southern District of Texas.


Sign up for our free newsletter:

Our privacy policy

no, thanks

Continue to site...