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Health Care Fraud News January 2015

Health care fraud is serious business. Stay clear of the path these providers chose.

Chicago, IL- 10/2014: A dermatologist was convicted (3 counts of wire fraud and 3 counts of mail fraud) of defrauding Medicare and private payors by submitting false claims for more than 800 patients totaling over $2.6 million. The provider falsely documented hundreds of medical records to support medically unnecessary, cosmetic treatments for patients falsely diagnosed with actinic keratosis. The provider is awaiting sentencing in February 2015 but could face a maximum penalty of 20 years in prison and a $250,000 fine on each count, or an alternate fine totaling twice the gross fraud loss or twice the gain, whichever is greater.

Cleveland, TN- 11/2014: A physical therapist plead guilty to using misbranded drugs with the intent to defraud Medicare. The plea agreement states that the doctor fraudulently billed Medicare for Botox injections he did not give. He received $7,482,968 in reimbursements over a four-year period for these false claims. During this time he did not purchase any FDA approved Botox and only 254 vials of non-FDA approved Botox, but billed Medicare for 17,766 vials. Sentencing is set for March, 2015. The provider faces a term of up to 3 years in prison, a fine of $250,000 or twice the amount of the gross fraud gain. He has already forfeited the accounts in two financial institutions totaling $6,765,608 and agreed to pay a monetary judgment in the amount of $717,359.

Los Angeles, CA- 12/2014: A physician who plead guilty in August, 2014 of receiving kickbacks for referring medically unnecessary patients to a DME Company was sentenced to 24 months in federal prison. He was also ordered to pay $931,118 in restitution. His referrals resulted in more than $1.7 Million fraudulent Medicare billings.

Dallas, TX- 12/2014: A family practice physician and a home health agency nurse were sentenced to 120 months and 48 months respectively in federal prison for their May, 2014 conviction of conspiracy to commit health care fraud. The physician was also convicted on 3 counts of health care fraud and 4 counts of making false statements. The home health agency recruited patients so that Medicare could be fraudulently billed for unnecessary home health services. The physician and nurse prepared fraudulent medical records making the services appear necessary. The physician certified that the patients needed home health services which were qualified for payment from Medicare.

New Orleans, LA- 12/2014: A home-health/DME company owner and a family practice physician pleaded guilty to conspiracy to commit health care fraud. The company owner also plead guilty to conspiracy to falsify records in a federal investigation. Recruiters were used to canvas New Orleans neighborhoods for Medicare numbers, which were then used to bill Medicare for services not medically necessary or not provided. The doctor admitted to signing home health referrals and wrote DME prescriptions that were used to support the fraudulent billings. He falsely certified patients as homebound and qualified for home health services.

Beaumont, TX- 12/2014: A 75-year old family practice physician was sentenced to 15 months in federal prison for his role in conspiring to have unlicensed individuals treat patients and then bill payors as if he had personally provided the services. He allowed unlicensed staff to prescribe controlled substances when he was not on the premises and allowed his office manager to distribute the controlled substances directly to patients. Losses to Medicare, Medicaid, Blue Cross Blue Shield and Aetna totaled $328,238.

Greenwood, MS- 12/2014: A nurse CEO of a hospice company pled guilty in February 2014 to conspiracy to commit health care fraud and was sentenced to 70 months imprisonment followed by 3 years of supervised release. The RN admitted to submitting fraudulent hospice charges to Medicare for patients who were not eligible for hospice and were never provided, or claims based on forged signatures of physicians. She was also required to pay $7,941,335 in restitution and forfeit 17 vehicles worth over $600,000 plus 12 pieces of real property valued at over $700,000.

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