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Provider Health Insurance Fraud Schemes, Settlements Top $310M

Law enforcement agencies have charged providers and organizations in health insurance fraud schemes more than $310 million in the opening weeks of 2018.

Law enforcement agencies charged providers $310 million in healthcare fraud

Source: Thinkstock

By Thomas Beaton

- Law enforcement agencies and federal healthcare administrators including HHS, the Office of the Inspector General (OIG), the FBI, and US Attorney's Offices across the country investigated provider healthcare schemes that defrauded Medicare and Medicaid more than $310 million.

The investigations led to criminal charges and one settlement to resolve False Claims Act allegations. Aggressive prosecution involving healthcare fraud perpetrators was a regularity in 2017 and looks to continue throughout 2018.

By the end of 2017, the Department of Justice (DoJ) recovered nearly $2.4 billion from healthcare fraud schemes, which accounted for 64 percent of the DoJ’s entire fraud recovery totals across all industries.

Enforcement agencies have recently charged alleged criminal entities with millions in kickback schemes, medically unnecessary prescribing activities, and unnecessary medical billing practices.

Texas mayor and healthcare group charged in a $150 million Medicare fraud conspiracy

Four individuals, including Rio Bravo, Texas mayor Francisco Pena, were charged for their role in a healthcare fraud scheme that included obstruction of justice and money laundering.

READ MORE: How Payer Philanthropy Can Address Social Determinants of Health

Prosecutors alleged that leaders in the Merida Health Care Group participated in kickbacks and bribes to Medicare directors, including Pena, in exchange for certifying patients for home health services.

Law enforcement officials also charged the four individuals for fraudulently keeping multiple patients on hospice services in order to increase Medicare revenues.

Rodney Mesquias, 47, and the owner of Medrida Group along with Henry McInnis, 47, and Jose Garza, 40, allegedly participated in elaborate profit distribution by moving proceeds to false Merida entities.

Pena is additionally accused of providing a false statement to the FBI, which said he didn’t know about or participate in the kickback scheme. The allegations also say that Mequias and McInnis provided a false statement to a federal grand jury.

Law enforcement and regulatory agencies including OIG, the FBI’s San Antonio Division, and Texas’ Health and Human Services Commission led investigations for this case.

Michigan clinic office manager pleaded guilty to claiming $131 million in unnecessary prescriptions

READ MORE: Top 5 Most Common Healthcare Provider Fraud Activities

Yasser Mozeb, 35, the office manager of the Tri-County Network in Detroit, MI, pleaded guilty to his involvement in a scheme that defrauded Medicare of $131 million through the use of medically unnecessary prescriptions.

Mozeb pleaded guilty to one count of conspiracy to commit health care fraud and one count of conspiracy to defraud the United States by paying and receiving kickbacks.

Mozeb admitted that he conspired with the owner of Tri-County Network, Mashiyat Rashid, to pay illegal kickbacks to Medicare beneficiaries and co-conspirator patient recruiters to obtain patients for Tri-County. He also admitted that he worked with Rashid to give individuals living with substance addiction additional prescriptions for oxycodone, hydrocodone and opana.

The guilty plea comes months after a co-conspirator of Mozeb’s also pleaded guilty in another Tri-County scheme that defrauded Medicare of $19 million.

Attorney General Jeff Sessions applauded the efforts of law enforcement and government entities, including HHS-OIG, the FBI, and the IRS, in preventing patient safety risks and combating high-profile healthcare fraud.

READ MORE: Medicare Fraud Schemes Bring Jail Time, Admissions, Repayments

“With one American dying of a drug overdose every nine minutes, we are facing the deadliest drug crisis in American history,” Sessions said.

“Sadly, some have chosen to take advantage of this crisis and exploit vulnerable patients for profit. At the Department of Justice we’ve taken a number of new steps this past year to fight opioid-related fraud. Today we have won another victory in this fight and I want to thank our FBI agents, DOJ attorneys, and everyone else who helped us bring the defendant to justice.”

Dental management company will pay $23.3 million to settle False Claims Act allegations

Benevis LLC, a dental management company, and its Kool Smiles subsidiary clinics will make a $23.3 million settlement payment to resolve False Claims Act allegations involving unnecessary pediatric dental services.

The government alleged between 2009 and 2011 that Benevis and Kool Smiles clinics across 17 states submitted false claims to state Medicaid programs for unnecessary baby root canals, tooth extractions, and stainless steel crowns. Additionally, the government alleged that Benefits sought payment for baby root canals that were never performed.  

The US also alleged that Kool Smiles clinics routinely pressured and incentivized dentists to meet production goals and drove overutilization of dental services.

“The allegations in these cases are particularly egregious because they involved medically unnecessary dental services performed on children,” said US Attorney John H. Durham for the District of Connecticut.  

“Exploiting needy children for financial gain is inexcusable.  The US Attorney’s Office in Connecticut is committed to aggressively pursuing health care providers that submit fraudulent claims to government healthcare programs.”

Enforcement agencies including US Attorney’s Offices in Connecticut, Texas, and Virginia investigated the allegations with additional support from National Association of Medicaid Fraud Control Units (NAMFCU).

 

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