Medicaid and Medicare Fraud

December 16, 2019

Florida Health Insurance Fraud Lawyer: Ten Retired NFL Players Charged with Fraud Involving a League Health Care Benefit Program

by Whittel & Melton, LLC

The Justice Department charged 10 former NFL players, among them a group of former Washington Redskins that includes running back Clinton Portis and cornerback Carlos Rogers, with defrauding a health-care program for retired players of nearly $4 million, according to court documents.

After an FBI investigation, the Justice Department filed charges Thursday morning in the Eastern District of Kentucky against Robert McCune, John Eubanks, Tamarick Vanover, Ceandris Brown, James Butler, Frederick Bennett, Correll Buckhalter, Etric Pruitt, Portis and Rogers.

The government also intends to charge former NFL wide receivers Joe Horn and Reche Caldwell with conspiracy to commit health-care fraud, according to a news release.

The specific combination of charges for the 10 players vary by individual but include conspiracy to commit health-care wire fraud, wire fraud and health-care fraud. Portis was charged with all three. The charges carry a legal maximum penalty of 50 years combined.

Four former NFL players were arrested Thursday morning, and the others, including Portis, are expected to surrender at some point. The arrested players were McCune in Georgia, Eubanks in Mississippi, Brown in Texas and Rogers in Georgia.

The players allegedly submitted false claims to the Gene Upshaw NFL Player Health Reimbursement Account Plan for reimbursement for medical equipment — such as hyperbaric chambers, cryotherapy machines, ultrasound machines used to conduct women’s health exams and electromagnetic therapy devices designed for use on horses — costing between $40,000 and $50,000. According to the indictments, the players fabricated documents, including invoices and prescriptions, to execute the plan.

Under the terms of the collective bargaining agreement, the Gene Upshaw NFL Player Health Reimbursement Account Plan is funded by NFL teams and jointly administered by the NFL and the NFL Players Association.

The accused players filed $3.9 million in false claims, and between June 2017 and December 2018, the health plan paid them more than $3.4 million on those claims, according to court documents.

“The expensive medical equipment described in the Reimbursement Request Forms that the Defendants submitted or caused to be submitted to the Plan were never purchased or received from the Participant, and the invoices from medical equipment companies, letters from health care providers, and prescriptions from health-care providers accompanying the Reimbursement Request Forms were all fabricated,” the indictment reads.

According to the indictments, the players fall into two groups: those who recruited former players and helped file fraudulent claims and others who agreed to provide their personal information knowing it would be used to defraud the health-care fund for fellow retired players. The players who filed the fraudulent claims on behalf of others received “payment of kickbacks and bribes” of up to $10,000 for each false claim.

McCune, a linebacker drafted by the Redskins in 2005 who played in the NFL until 2009, allegedly filed the first fraudulent claim. On Oct. 3, 2017, McCune filed a reimbursement claim in Buckhalter’s name for a PEMF 8000 Equine Unit, electromagnetic therapy mobile device used on horses. He also filed a claim for an electromagnetic therapy magnetic mattress and three associated “butterfly loops” at a total cost of nearly $40,000.

Later that month, McCune apparently filed false claims in the names of Eubanks and Brown. Between February 2018 and April 2018, according to the documents, McCune filed another six claims using the names of Vanover, Portis, Butler and Bennett.

On March 8, 2018, McCune filed a false claim under Portis’s name for a “Crome Pro Cryosauna” — a cryotherapy device that looks like a stand-up tanning bed — and a “Sculpting CryoLipolysis,” equipment used for the cosmetic removal of body fat. Combined, the equipment cost more than $54,000, one of the costliest claims noted in the documents.

The documents allege Buckhalter, a running back for the Philadelphia Eagles and Denver Broncos from 2001 to 2010, used the same scheme with the help of Rogers, recruiting new players to file similar reimbursement forms.

McCune and Buckhalter allegedly called the number that handles reimbursement requests and impersonated other players to check the status of false claims submitted on their behalf.

The investigation was triggered, officials said, by health insurer Cigna, which first took notice of suspicious claims.

Benczkowski said the Justice Department pursued the case “because of the potential impact of these crimes — not only the amount of money at stake but the fact that the crimes potentially impacted a very important benefit that was collectively bargained between the league and the players association to benefit former players and their spouses and their dependents.

Health care fraud is a huge government priority at the moment. At this time, it may be the most commonly prosecuted kind of white collar crime in federal court. The Department of Justice and the Department of Health and Human Services’s Office of Inspector General are spending vast resources investigating and prosecuting health care fraud cases.

The majority of healthcare fraud charges arise from fraudulent billing allegations. They can include any sort of the following:

False billing
Upcoding (billing a code with a more expensive service)
Billing for services not rendered
Billing for unnecessary tests and procedures
Billing for unnecessary medical equipment
Double-billing (billing for Medicaid/Medicare and also private insurance)
Billing for more time than provided
Kickbacks and referrals
Falsifying medical records/documents

May 13, 2019

Florida Dad Who Bribed Son Into Penn Found Guilty in $1.3 Billion Health Fraud Scheme

by Whittel & Melton, LLC

A Florida man was convicted Friday of running an 18-year, $1.3 billion health-care fraud that prosecutors called the largest scheme of its kind ever charged by the Justice Department.

The 50-year-old Miami Beach resident apparently used a network of nursing homes and assisted-living facilities in South Florida to defraud U.S. government healthcare programs while providing inadequate and unnecessary care to patients, prosecutors said.

The man is apparently made off with at least $37 million for himself from 1998 to 2016, according to prosecutors, using the money to finance a lavish lifestyle of fancy cars and a $360,000 watch.

The man also used some of the proceeds from the fraud to bribe the University of Pennsylvania basketball coach to help get his son into the school, prosecutors allege. The coach pleaded guilty to money laundering last year in connection with the case.

Prosecutors said the man bribed doctors to admit patients to the facilities he operated. The patients didn’t get appropriate care and sometimes received unnecessary services for which the man then billed the U.S. government.

The man also bribed a Florida state regulator to learn about surprise inspections of company facilities ahead of time, prosecutors said.

The total value of fraudulent claims that the man’s companies submitted to Medicare and Medicaid exceeded $1.3 billion, according to prosecutors.

A jury found the man guilty on 20 counts in U.S. district court in the Southern District of Florida. Charges included conspiracy to defraud the United States, receiving kickbacks, money laundering and conspiracy to commit bribery. Two co-conspirators pleaded guilty. Sentencing hasn’t been scheduled.

Health care fraud is a very serious crime that the federal government and the state of Florida will pour countless resources into to uncover alleged fraud. Anyone from an individual doctor to a billing company to an entire hospital system can be the target of a lengthy investigation.

The government is aggressive when it comes to investigating these claims. You need an equally aggressive attorney fighting on your side to protect you from health care fraud charges. Our South Florida Medicare and Medicaid Fraud Defense Attorneys at Whittel & Melton understand how to defend these health care fraud charges and will work tirelessly to protect you from the government’s powerful grasp. We will provide you with an honest assessment of your situation and help you understand the possible defenses that may be available. We want to minimize any damage to you and your reputation.

May 8, 2018

CityMD Ordered to Pay $6.6 Million for Submitting False Claims to Medicare

by Whittel & Melton, LLC

CityMD, a popular chain of 88 urgent care centers mostly in the New York metropolitan area, has agreed to pay $6.6 million for submitting false claims to Medicare, according to the Manhattan U.S. Attorney’s Office.

The payment settles a civil fraud lawsuit brought by a whistleblower and the Manhattan U.S. Attorney’s Office.

CityMD is accused of improperly billing Medicare at a significant cost to taxpayers.

The settlement is a way to hold CityMD accountable both through the significant monetary payment and the detailed admissions made by CityMD.

As part of the settlement, CityMD apparently admitted it tricked Medicare by billing the federal program for lengthier and more complex procedures than its doctors actually performed.

The urgent care centers also confessed to billing Medicare for services performed by physicians not credentialed with the federal program.

The Manhattan U.S. Attorney’s Office joined a whistleblower’s False Claims Act lawsuit that had been filed under seal until the settlement was reached.

Being accused of collecting illegitimate healthcare funds from the federal government is a serious offense, and if this is proven in court, you could be facing pretty severe consequences. Medicare fraud is punished much more severely now than ever before. Punishments for this type of fraud generally stem from the federal sentencing guidelines. Depending on the offense, penalties can include maximum sentences ranging from 6 months to decades in prison, along with hefty fines. Moreover, restitution payments for wrongfully obtained funds will be ordered to reimburse the federal government.

March 27, 2018

Latest Medicare Fraud Schemes Targeted $139.4M via Kickbacks

by Whittel & Melton, LLC

Three Medicare fraud schemes in recent weeks have targeted a total $139.4 million, which led the Department of Justice to seek multiple convictions and a combined 33 years in prison sentences.

Each of the alleged schemes involved the use of provider kickbacks, a popular activity in healthcare, to entice healthcare professionals to inappropriately redirect clients and beneficiaries to specific healthcare businesses.

Law enforcement officials began their crackdown on Medicare fraud earlier in the year with a mix of provider convictions and settlements involving roughly $3 million dollars.

Combating healthcare fraud continues to be a top priority for law enforcement officials because of the dangers it presents to vulnerable beneficiaries in the Medicare program, as well as the potential to recover billions in Medicare spending.

A Detroit provider was sentenced to six years in prison for $10.4 kickback scheme. The case apparently involved kickbacks for unnecessary electromyogram (EMG) tests and physical therapy tests.

He was convicted of one count of conspiracy to commit healthcare fraud, one count of wire fraud, two counts of receiving healthcare kickbacks, and had to personally forfeit $1.69 million.

A 70-year-old Boca Raton man was sentenced to five years in prison for $63 million in home health care fraud. Him and eleven other co-conspirators apparently submitted false and fraudulent claims to Medicare through kickbacks that were medically unnecessary, were not eligible for Medicare reimbursement, or were never provided by his clinic.

The man was found guilty of hiding the payments by using his clinic to provide a salary through the kickbacks, and was paid a flat rate based on the number of individuals he referred. The man also admitted patients for partial hospitalization program (PHP) services even though he knew the patients didn’t qualify for PHP service.

He was convicted of one charge of conspiracy to defraud the United States and to receive healthcare kickbacks. He personally had to forfeit $9.9 million and a personal money judgement over $400,000.

The case was investigated by the FBI, HHS, and OIG with supervision from the Medicare Fraud Strike Force and the US Attorney’s Office for the Southern District of Florida.

A 52-year-old Miami owner of multiple home health agencies was sentenced to 20 years in prison for $66 million in Medicare fraud that used his network of 20 home health agencies to host an elaborate kickback scheme.

The man and other co-conspirators were found guilty of recruiting individuals to represent his home health agencies in order to hide the man’s identity as they paid illegal bribes and kickbacks to patient recruiters to refer patients to these agencies.

The man also admitted that he submitted false and fraudulent home healthcare claims for Medicare beneficiaries that did not qualify for many services.

He had to forfeit $66.4 million in restitution and is convicted of one count of conspiracy to commit healthcare fraud and wire fraud.

The case was investigated by the FBI and was brought forward by the Medicare Fraud Strike Force and the US Attorney’s Office for the Southern District of Florida.

The Federal Anti-Kickback Statute makes it a felony to knowingly and willfully offer, pay, solicit, or receive remuneration, directly or indirectly, in order to induce business that is reimbursable under any federal health care program, such as Medicare or Medicaid. If accused of this crime, you could be facing both criminal and civil penalties.

Are you under investigation for Medicare fraud? You are not alone. About 1,400 individuals are indicted in federal court for health care fraud every year and more than 2,500 individuals are currently being investigated for Medicare fraud.

March 20, 2018

Florida Man Gets 20 Years for $66 Million Medicare Fraud Scheme

by Whittel & Melton, LLC

A 52-year-old Miami businessman has been given a 20 year prison sentence for his apparent role in a Medicare fraud scheme.

His eight homes around Miami-Dade County, at least three cars, and a meat supermarket have been seized as a part of his $66 million in restitution.

He apparently owns 19 healthcare agencies as well. According to court documents, he tried to hide his ownership of the health agencies as part of yet another massive South Florida Medicare scam.

He apparently recruited others to falsely and fraudulently represent themselves to be the owners of the agencies in order to hide his identity and ownership interest, according to the court documents. These nominee owners completed and signed Medicare enrollment applications that fraudulently misrepresented the identities of the agencies’ ownership interest and managing control of the true owners and failed to disclose the man’s ownership interest and managing control of the agency, contrary to Medicare’s requirements.

From 2007 through 2015, the man and his nominees are accused of paying patient recruiters kickbacks to refer Medicare beneficiaries to the man’s owned facilities. The facilities billed Medicare for expensive healthcare services such as physical therapy and home health. Most of the referred beneficiaries didn’t quality for home health services or the services were imaginary.

Medicare is a federal program that provides health insurance to all American citizens over the age of 65. The government treats medicare fraud quite seriously and will prosecute anyone suspected of defrauding the program.

July 26, 2016

Three Charged in $1 Billion Medicare Fraud Scheme In Miami

by Whittel & Melton, LLC

Three people have been convicted of alleged Medicare and Medicaid fraud in a $1 billion scheme in Miami.

“This is the largest single criminal healthcare fraud case ever brought against individuals by the Department of Justice,” said Leslie R. Caldwell, Assistant Attorney General the department’s criminal division, in a statement issued Friday.

A 47-year-old man allegedly led a scheme that referred Medicare and Medicaid beneficiaries who did not qualify to skilled nursing and assisted living facilities. The man owned 30 such facilities, giving him access to thousands of beneficiaries, according to reports.

Also charged in the scheme are a 49-year-old hospital administrator and a 56-year-old physician’s assistant.

The three also are accused of accepting kickbacks, disguised as charitable donations or paid in cash, for directing the beneficiaries to selected health care providers, including pharmacies, health care agencies and mental health centers, according to investigators.

Medicare or Medicaid fraud happens when a provider knowingly makes a false or misleading statement or representation for use in obtaining reimbursement from the medical assistance program. Medicare and Medicaid providers include doctors, dentists, hospitals, nursing homes, pharmacies, clinics, counselors, personal care/homemaker companies, and any other individual or company that is paid by the the programs.

Medicaid fraud includes, but is not limited to:

Billing for medical services that were never performed, known as phantom billing
Billing for a more expensive service than was actually performed, known as upcoding
Billing for multiple services that should be combined into one billing, known as unbundling
Billing several time for the same medical service
Dispensing generic drugs and billing for brand-name drugs
Giving or accepting something in return for medical services, which is known as a kickback
Providing unnecessary services
Filing false cost reports

July 20, 2016

South Florida Doctor Gets 3 Years for Medicare Fraud

by Whittel & Melton, LLC

A South Florida doctor will spend more than three years in federal prison after pleading guilty to falsely diagnosing hundreds of patients in a Medicare fraud scheme.

Court records show the 57-year-old Delray Beach doctor was also ordered Wednesday by a federal judge to pay more than $2.1 million in restitution to the government. The man previously pleaded guilty to health care fraud.

Authorities claim the man falsely diagnosed 387 patients enrolled in the Medicare Advantage program with a rare spinal condition. The patients were enrolled in a Humana Inc. health plan that was reimbursed for each diagnosis by Medicare.

The federal program paid out $2.1 million in excess benefits, 80 percent of which went to the doctor. Almost none of the patients actually had the rare spinal condition, according to reports.

Medicare and Medicaid fraud is taken quite seriously on local, state and federal levels. It is important to note that these cases are heavily investigated before charges are brought forth. With that said, you will most likely know about the possibility of being charged long before an indictment is filed against you.

January 14, 2014

Miami medical clinic owner pleads guilty to conspiracy to commit health care fraud

by Whittel & Melton, LLC

A Miami woman plead guilty this week for her part in an $8 million South Florida medicare fraud scheme centering around a now-defunct home health care company.

According to court documents, the woman’s co-defendants were patient recruiters for the owners and operators of Flores Home Health, a Miami home health care agency that purported to provide home health and physical therapy services to Medicare beneficiaries. The defendant herself also owned and operated a Miami medical clinic that provided fraudulent prescriptions to these patient recruiters as well as to the owners and operators of Flores Home Health.

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Investigations by the Medicaid Fraud Strike Force revealed that the defendants would first recruit patients for Flores Home Health and then would solicit and receive kickbacks and bribes from the owners and operators of Flores Home in return for allowing the agency to bill the Medicare program on behalf of the recruited Medicare patients. These Medicare beneficiaries were billed for home health care, like expensive physical therapies, that were not medically necessary or never provided at all.

The defendant plead guilty in U.S. District Court of and for the Southern District of Florida, and is expected to be sentenced in mid-March. Conspiracy to commit health care fraud carries a maximum penalty of 10 years in federal prison.

State and Federal Agents target all players in these types of schemes, many times alleging coding irregularities, kickbacks to patients and staff, medicaid billing for services not provided, and over charging for medical services.