Category: MM Curator

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Safety-net providers sue to stop Medicaid carveout

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Facilities that make lots of money off the 340B scam are now resorting to “equity” as their last defense against the long-planned reform in NY.

 
 

 
 

Clipped from: https://www.politico.com/newsletters/weekly-new-york-health-care/2023/03/27/safety-net-providers-sue-to-stop-medicaid-carve-out-00088890

By ZACHARY SCHERMELE 

03/27/2023 10:00 AM EDT

Presented by HANYS and GNYHA

Beat Memo

Two safety-net providers are taking the state Health Department to court in a last-ditch effort to prevent a disputed Medicaid carveout from taking effect.

Evergreen Health, along with Heritage Health and Housing, a not-for-profit that operates a federally qualified health center in Harlem, filed a lawsuit in New York Supreme Court on Friday seeking an injunction of the carveout before it takes effect April 1.

They allege the long-planned effort to merge Medicaid pharmacy benefits under a single state program violates federal law and is discriminatory.

The litigation escalates an ongoing battle at the eleventh hour over the proposed change to how millions of New Yorkers will soon access their medication. The plan, a remnant of Gov. Andrew Cuomo’s last fiscal budget proposal, in 2021, could potentially save the state hundreds of millions of dollars, according to Gov. Kathy Hochul’s proposed budget.

But fierce opposition, mainly from safety-net providers who financially depend on a decades-old federal program known as 340B, which would be sidelined under the new rules, stalled the reform for years.

At a budget hearing in late February to discuss the carveout, Housing Works CEO Charles King was one of several protesters arrested on trespassing charges after disrupting the proceedings to oppose the measure.

New York City Mayor
Eric Adams and Ashwin Vasan, the city’s health commissioner, have also come out against the carveout, saying it would disproportionately harm LGBTQ patients and patients living with HIV.

“DOH will wreak immeasurable harm upon New York’s safety-net health care providers and the largely low-income persons dependent upon those providers for their health care and medications,” the complaint says.

Supporters of the program, including the Pharmacists Society of the State of New York, say that community pharmacies need it to survive, and that the change would allow patients greater access to choose where they get their medications.

The New York State Health Department did not immediately respond to a request for comment on Sunday.

IN OTHER NEWS:

— No one spoke up for or against proposed rate changes to ambulance fees in New York City at a public hearing Friday, leading FDNY officials to close the hearing early. The changes, which were first reported by POLITICO, would raise the cost of basic life-support ambulance services to $1,385 from $900. They would also charge patients $20 per mile traveled rather than $15, among a few other hikes.

The new fee schedule would ultimately bring in more than $16 millions in revenue for the city in fiscal year 2024, an FDNY spokesperson told POLITICO in February. It is expected to go into effect in the spring.

In a written statement to the FDNY, David Jones and Stephen Krause, the president and executive vice president of the nonprofit Community Service Society, opposed the new fee schedule, saying it would have the “unintended consequence of compelling New Yorkers to forgo medically necessary ambulance services to avoid the prospect of a large bill.”

ON THE AGENDA THIS WEEK:

Tuesday at 10:30 a.m. — The Cannabis Association of New York will hold a press conference as it lobbies lawmakers in Albany.

Thursday at 10 a.m. — The New York City Council’s Health Committee will hold an oversight hearing on improving access to in-community and at-home health care.

GOT TIPS? Send story ideas and feedback to Maya Kaufman at mkaufman@politico.com.

Want to receive this newsletter every weekday? Subscribe to POLITICO Pro. You’ll also receive daily policy news and other intelligence you need to act on the day’s biggest stories.
 

Odds and ends

NOW WE KNOW — Having trouble sleeping? You might live in the wrong city.

TODAY’S TIP — Could the causes of eczema be in the air we breathe?

STUDY THIS — The use of certain hormonal birth control methods may be associated with a 20-30 percent increased risk of breast cancer, according to researchers at Oxford.
 

What We’re Reading

— Patients on the drug aripiprazole should be better informed about the risks of gambling addiction, The Guardian reports.

— Via the Huffington Post: The Ozempic craze has pushed people in eating disorder recovery a step closer to relapsing.

— U.S. life expectancy remains on the decline relative to other countries.

— Cannabis use at older ages can carry special risks. Read what they are.

— The first signs of Alzheimer’s might be in your eyes, new research suggests.

— Via The New York Times: “Philadelphia tells residents to consider bottled water after chemical spill”
 

AROUND POLITICO

— Florida is using a little-known law to punish abortion clinics, reports Arek Sarkissian.

MISSED A ROUNDUP? Get caught up on the New York Health Care Newsletter.
 

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RX- Another Voice: Medicaid pharmacy program reform is greatly needed

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: An op-ed in favor of reforming how NY Medicaid pays for Medicaid drugs.

 
 

 
 

 
 

Clipped from: https://buffalonews.com/opinion/another-voice-medicaid-pharmacy-program-reform-is-greatly-needed/article_8831c81e-c4c9-11ed-8f1d-c7a7f811ea6c.html

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New York is reforming its Medicaid pharmacy program to remove managed care and pharmacy benefit managers (PBMs) and directly administer these benefits for enrollees. This change cannot come soon enough.

Health insurance plans and PBMs are paid to administer the pharmacy program and patients are required to participate in one of 16 managed plans. They can only use pharmacies in the PBM network. Patients are precluded from using a pharmacy that may be in their neighborhood or close to their place of work.

When a managed care plan in Ticonderoga recently dropped one of the only two pharmacies in the area from its network, patients were unable to obtain needed medications. We must do better than having the state pay financially motivated corporations to make business decisions that disrupt and restrict patient access to needed care.

Plans have their own drug formulary. Medicaid enrollees can only use drugs on the plan formulary, which means that what may be covered for one patient may not be covered for another. The current system also imposes significant administrative burdens on prescribers to comply with the complex maze of plan requirements, protocols, processes and paperwork in order to help our patients get the drug coverage they need and deserve. Every day, physicians deal with plan and PBM denials, delays and rejections that waste their time and delay patient access to treatment.

Come April 1, News York State will launch the New York State Medicaid pharmacy program known as NYRx. It will provide one formulary covering all FDA-approved medications. NYRx has one set of rules for prescribers and will provide better access to lifesaving therapies for Medicaid patients.

The New York State Academy of Family Physicians was the first medical society in New York to advocate for a single payer system of universal health. We see the state’s decision to launch NYRx as a first and transformative step toward reform of health care in New York.

Absent enactment of single payer legislation, the academy has advocated for streamlining and standardizing health coverage to reduce administrative burdens and make health care easier to access for patients and for those who care for them. NYRx will simplify the pharmacy benefit for all with Medicaid. Patients will not be limited by pharmacy network requirements and varying plan requirements and processes. Also, removal of for-profit health plans and PBMs from this benefit will save money that can be applied to Medicaid coverage and patient services.

Health plans, PBMs and others oppose NYRx. The governor and Legislature must resist these efforts. New Yorkers with Medicaid need a simplified and standardized pharmacy benefit directly administered by New York State, as was the case a decade ago. NYRx is a model for the much broader system reforms we continue to advocate for to benefit all New Yorkers.

Dr. Andrew Symons, of Tonawanda, is president of the New York State Academy of Family Physicians.

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FWA- If the government cut Medicare fraud, it wouldn’t have to cut Medicare

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Ruh-roh. Yet another person saying the quiet part out loud.

 
 

 
 

Clipped from: https://thehill.com/opinion/finance/3910370-if-the-government-cut-medicare-fraud-it-wouldnt-have-to-cut-medicare/

 
 

iStock.

President Biden says he’s not gonna let Republicans cut the financially challenged Medicare program. “A lot of Republicans, their dream is to cut Social Security and Medicare,” Biden said in February. “Well, let me say this: If that’s your dream, I’m your nightmare.” Well, how about at least cutting Medicare fraud?

Medicare and Medicaid fraud is rampant. The National Health Care Anti-Fraud Association recently estimated Medicare and Medicaid fraud totaling about $100 billion a year. Others believe that’s a conservative estimate.

New video from CNBC’s Contessa Brewer highlights some of the problems in South Florida, which is ground zero for Medicare fraud. Brewer says the “business of stealing Medicare and Medicaid cash has never been as brazen.”

Maybe, but it’s been very brazen for decades. A young Chris Wallace, then with ABC, reported on Medicare fraud in 1994. And here’s a “60 Minutes” report from 13 years ago in which reporter Steve Kroft warns viewers that the story may raise their blood pressure. And it should.

And while those stories are about Florida, here’s a decade-old National Public Radio story about a Texas doctor indicted for $375 million in fraudulent Medicare and Medicaid billing.

One reason criminals can steal so much is Medicare and Medicaid spend so much.

Total Medicare spending in 2022 was $982 billion, with $755 billion of that total coming from the federal government and $227 billion in premiums paid by Medicare beneficiaries to the government. Medicaid, which is a federal/state health insurance program for low-income families, spent $864 billion in 2022.

The federal government estimates that 7.5 percent of spending on traditional Medicare in 2022 was for “improper payments,” which includes both fraud and errors in billing.

For Medicaid, it was 15.6 percent.

What all the imprisoned criminals interviewed in these stories agree on is that defrauding Medicare and Medicaid is easy. Criminals open a small office because Medicare requires that vendors have an address. They put in a desk and chair, though there is seldom anyone actually in the office. Then they buy a list of stolen Medicare beneficiaries’ information and start billing the government.

The biggest scams often involve what’s known as durable medical equipment (DME), which includes a range of items such as wheelchairs, prosthetic limbs and oxygen-related equipment.

Note that this isn’t a rap on federal law enforcement trying to catch the fraudsters. They are doing their best, though they are understaffed and underfunded. And they do catch some of the criminals, as the news stories demonstrate.

Centers for Medicare and Medicaid officials boast that they have been reducing improper payments and fraud, and kudos to them for that. But no one really knows how much Medicare and Medicaid fraud there is, because many fraudsters may never be caught.

The best way to identify the criminals may be when they start getting really greedy. Here’s a good example from a series on Medicaid fraud that appeared in the New York Times in 2005. “It has drawn dentists like Dr. Dolly Rosen, who within 12 months somehow built the state’s biggest Medicaid dental practice out of a Brooklyn storefront, where she claimed to have performed as many as 991 procedures a day in 2003.”

Had Dr. Rosen kept her billings to, oh, say, 500 procedures a day, she might have stayed under the government’s radar. That’s a joke, but you get the point.

One Medicaid official in the Times story estimated that perhaps 40 percent of New York City’s Medicaid spending was fraudulent. 

Texas had its own Medicaid dental fraud. Several Texas dentists were charged and convicted of scamming the system of millions of dollars by putting braces on children who didn’t need them. As the Dallas ABC affiliate, WFAA, reported, “Medicaid records showed Texas spent $184 million on Medicaid orthodontics in 2010 — nine times more than California, which spent $19.5 million.”

It was WFAA that discovered and exposed the fraud, not federal or state officials.

The point is that if the federal government were better at preventing Medicare and Medicaid fraud, the programs could save perhaps $100 billion a year or more. While that wouldn’t solve Medicare’s long-term financial challenges, it would certainly help delay the day of reckoning.

No private sector company could survive with that much fraud. Credit card companies, and even private health insurers, have much lower fraud rates.

While no one defends the fraud, many politicians and bureaucrats don’t seem that interested in trying to fix it. Indeed, when Republican state legislators propose verifying state Medicaid rolls to ensure recipients are qualified, Democrats usually push back.

What’s clear is that there is a way to cut Medicare without hurting Medicare patients, and that’s to cut the fraud. But it’s much less work, and perhaps more politically rewarding, to just attack political opponents.

Merrill Matthews is a resident scholar with the Institute for Policy Innovation in Dallas, Texas. Follow him on Twitter @MerrillMatthews.

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MCOs- UPMC Review Confirms PA Medicaid as National Model for Behavioral-Physical Health

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Some highlights of what UPMC is doing in its whole-person model. TL/DR: increased SA treatment, increase primary care and increase screenings for SDH needs.

 
 

 
 

 
 

Clipped from: https://www.miragenews.com/upmc-review-confirms-pa-medicaid-as-national-971974/

PITTSBURGH, PA (March 22, 2023)—Experts from UPMC Health Plan and Community Care Behavioral Health Organization recently published a state mental health policy description that shows how Pennsylvania’s county-based model of Medicaid behavioral health managed care exemplifies the integration of services to support “whole-person” care. The piece appears in the journal Psychiatric Services.

In Pennsylvania, Medicaid behavioral health is funded through and managed by counties that contract with behavioral health managed care organizations. The counties also manage human services, such as those related to aging, children and youth, and housing. Having all these services coordinated under one umbrella allows for the use of a “human services integration” model for delivering Medicaid-funded behavioral health and other supportive services. This model supports engagement with physical health managed care organizations and multidisciplinary care teams for individuals with co-occurring medical health conditions.

“The strategies, lessons learned, and metrics we have outlined demonstrate that a whole-person approach to behavioral health care facilitates positive outcomes, coordinates community and physical health supports and resources, and aligns providers to focus on the best interest of the individuals we serve,” said Matthew Hurford, MD, President of Community Care Behavioral Health Organization and Vice President of Behavioral Health for UPMC Insurance Services. “Coordinating and managing care with county partners ensures a personalized approach to care that more smoothly and comprehensively integrates behavioral, physical and other needs.”

This whole-person care model has resulted in the following noteworthy outcomes:

  • The number of Community Care members receiving medication-assisted treatment—a highly effective form of substance use treatment that involves prescription medication and therapeutic support—increased 43 percent from January 2018 to June 2022.
  • Primary and specialty care use in a widespread health integration model increased over a two-year period by more than 30 percent, while overall medical costs decreased by 15 percent due to a reduction in hospital-based services.

 
 

  • Increased routine screening of social needs built into several managed care and provider-based care strategies resulted in connecting individuals with resources to address health disparity-related needs, including housing, food security, employment, and job training to better support long-term recovery.

“We believe this integrated approach leaves no stone unturned in addressing the clinical and other needs of individuals seeking behavioral health services,” said James Schuster, MD, Chief Medical Officer for the UPMC Insurance Services Division. “This kind of coordination and cooperation may, in part, be why Mental Health America once again rated Pennsylvania among the top three states in the country for addressing mental health challenges.”

/Public Release. This material from the originating organization/author(s) might be of the point-in-time nature, and edited for clarity, style and length. Mirage.News does not take institutional positions or sides, and all views, positions, and conclusions expressed herein are solely those of the author(s).View in full here.

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MH/BH- SAMHSA Gives $1M to 15 States Competing for Spot in CCBHC-Medicaid Demonstration

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: SAMHSA is restarting the CCBHC grants after a 7 year break.

 
 

 
 

Clipped from: https://bhbusiness.com/2023/03/21/samhsa-gives-1m-to-15-states-competing-for-spot-in-ccbhc-medicaid-demonstration/

States vying for spots in the Medicaid demonstration program for certified community behavioral health clinics (CCBHCs) are getting a financial boost from the federal government.

The Substance Abuse and Mental Health Services Administration (SAMHSA) awarded 15 states $1 million planning grants to help pay for the application and development process required to join a Medicaid demonstration program. The program increases funding for CCBHCs, and creates prospective payment models, giving CCBHCs the needed stability and flexibility to provide comprehensive behavioral health services.

However, only 10 states that get planning grants can join the demonstration program in 2024. This is an application year in the competitive process to join the Medicaid demonstration.

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“I think states that see the value in that model of care are really not inclined to wait around four to six years from now,” Rebecca Farley David, a senior advisor for the National Council for Mental Wellbeing, told Behavioral Health Business. “They want to go after it right now. They want to make those transformations. They want to start to see the results.”

Eventually, all states will have the chance to join the demonstration program. However, states that are actively reforming their mental health systems would rather not be left in the cold until the next round of admissions to the program in 2026.

This is the first time the federal government has released these planning grants since 2016.

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The states that got the planning grants are Alabama, Delaware, Georgia, Iowa, Kansas, Maine, Mississippi, Montana, North Carolina, New Hampshire, New Mexico, Ohio, Rhode Island, Vermont and West Virginia.

CCBHCs must provide nine core services, which give patients timely access to encompassing and coordinated mental health, addiction treatment and psychiatric services. 

The National Council for Mental Wellbeing, a nonprofit advocacy group, tracks more than 500 CCBHCs operating in 46 states plus Puerto Rico, Washington D.C. and Guam.

Only 10 states presently participate in the Medicaid prospective payment demonstration. The Bipartisan Safer Communities Act expanded the demonstration to include 10 new states every two years starting in 2024.

Safety net clinics that become CCBHCs in the first place can serve 900 more people than before receiving the designation, a 23% increase in access to behavioral health services, according to a National Council for Mental Wellbeing.

I think states that see the value in that model of care are really not inclined to wait around four to six years from now.

Rebecca Farley David, senior advisor for the National Council for Mental Wellbeing

The Medicaid demonstration program is meant to give CCBHCs the stability and financial security to provide expansive and coordinated services. After detailed negotiations between states and clinics that are influenced by federal guidance, states establish prospective per-day or per-month payments. In contrast, present Medicaid fee-for-service funding often fails to provide the margins needed to sustain community-focused clinics, David said.

The demonstration program is fundamentally different from the various waiver programs. Waivers are accessible to any state at any time. Demonstration programs are restricted in multiple ways — in this case, by the number of participants or other requirements.

The intensive nature of the demonstration program requires significant resources from states to apply and be ready for it, hence the planning grants from SAMHSA.

“When you look at the CCBHC model and what it requires of clinics and what it requires a state, it really is a very intense and transformative effort,” David said. “It’s not as simple as the states applying for the opportunity to be in the demonstration. They have to do all kinds of work during the planning year in order to become ready to participate in the demonstration should they be chosen.” 

The states certify their clinics and then develop new payment rates and models, billing and payment processes and make community needs assessments to measure how and which clinics will face demands for services, David said.  

The CCBHC model was created in 2014 via the Excellence in Mental Health Care Act. Since its implementation, CCBHCs have been able to increase staffing levels. In 2022, 450 active CCBHCs hired 11,240 new staffers as of August 2022.

Interest in the model has ballooned in recent years as the coronavirus pandemic revealed and worsened the nation’s behavioral health struggles. CCBHCs have received major backing and expansion from Congress via the most recent omnibus funding bill and the Bipartisan Safer Communities Act, which passed on the heels of the Uvalde, Texas massacre.

The interest in growing the model continues within the Biden administration. The administration’s proposed budget for the federal fiscal year 2024 includes extended funding for CCHBCs and several transformative efforts that total about $656 million.

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FWA (NY)- Schenectady ambulette service pays $800K over Medicaid fraud

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Ismat Farhan stole $862,000 from you via your W-2 using a services not provided scam for his ambulance company. He did not say thank you.

 
 

Clipped from: https://www.timesunion.com/news/article/schenectady-ambulette-service-pays-800k-medicaid-17849729.php

Ismat Farhan, owner of USA Medical Transport, will pay $862,500 to the New York State Medicaid Program, according to the settlement.

 
 

SCHENECTADY — New York Attorney General Letitia James on Monday announced a settlement with the owner of a Schenectady-based medical transport company that was found to have billed Medicaid at least $400,000 for transportation services that were not provided.

Investigators determined that Ismat Farhan, through his company USA Medical Transport, submitted more than 2,500 false claims where either the transportation services never happened, did not occur as described or lacked the required documentation, according to the settlement agreement.

“Medicaid is meant to help support the medical needs of vulnerable New Yorkers, not to pad a company’s profits,” James said in a statement. “Farhan and USA Medical Transport took advantage of their patients and taxpayers by billing Medicaid for thousands of services that were never provided.”

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Farhan will pay $862,500 to the state’s Medicaid program, according to the settlement.  

Under state and federal false claims law, state authorities can fine Medicaid providers up to three times the amount they can prove was fraudulently billed. It’s common for the state to settle with the provider for double the amount, according to the attorney general’s office.

USA Medical Transport is still providing services. An attorney for Farhan declined to comment on the settlement. The agreement requires 25 percent of the company’s Medicaid reimbursements to be held back to satisfy the settlement.

Medicaid recipients are eligible to receive transportation to and from appointments with health care providers. Medicaid reimburses enrolled transportation companies for these services. To operate as a Medicaid transportation provider, a transportation company must certify that it will follow the Medicaid program’s rules and regulations, including submitting claims only for services that took place and maintaining thorough records documenting those claims.

State investigators found that between June 2015 and February 2020, Farhan submitted fraudulent claims to Medicaid, including for rides that were not provided, mileage amounts significantly greater than the ride, single rides that should have been bundled as a group ride, and tolls that did not occur.

The company also reported rides by drivers with suspended licenses, including Farhan.

The investigation was conducted by the Albany Regional Office of the Attorney General’s Medicaid Fraud Control Unit. The unit seeks to identify Medicaid fraud and protect nursing home residents from abuse and neglect. Anyone with information about Medicaid fraud or about an incident of abuse or neglect of a nursing home resident can file a confidential complaint online or call the MFCU hotline at 800-771-7755. 

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FWA- Northern District of Ohio | Jury Convicts Pair of Fraud and Health Care Fraud in Toledo

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Mr. and Mrs. Oliver Jenkins stole an undetermined amount from you via your W-2, using a scam they perpetrated on Medicaid dementia patients. They did not say thank you.

 
 

 
 

Clipped from: https://www.justice.gov/usao-ndoh/pr/jury-convicts-pair-fraud-and-health-care-fraud-toledo

TOLEDO, Ohio – First Assistant United States Attorney Michelle M. Baeppler announced that a federal jury convicted Dr. Oliver Jenkins, age 60, and Sherry-Ann Jenkins, age 58, of Jessup, Georgia, of conspiracy, mail fraud, wire fraud, and health care fraud on Friday, March 17, in Toledo, Ohio following a two- week trial before Judge Jack Zouhary.

According to court documents and evidence presented at trial, Dr. Oliver Jenkins, who was an Ear, Nose, and Throat M.D. at the Toledo Clinic, and his wife, Sherry-Ann Jenkins, who had a Ph.D. but was not licensed to practice medicine in Ohio, started a new business called the “The Toledo Clinic Cognitive Center.” The Jenkinses represented to the Toledo Clinic that patients suspected of cognitive disorders, particularly dementia and Alzheimer’s Disease, could come to the Cognitive Center for neurocognitive testing, diagnosis, treatment, and referrals, and that Sherry-Ann Jenkins would administer the neurocognitive testing under the supervision of Dr. Oliver Jenkins. The Jenkinses represented that Dr. Oliver Jenkins would make a diagnosis, and provide medical treatment, or a referral. Instead, the Jenkinses engaged in a scheme to defraud. Dr. Oliver Jenkins never saw or treated patients at the Cognitive Center. Sherry-Ann Jenkins ordered PET scans of patients’ brains, interpreted the scans, diagnosed patients, including a college-aged student, with Alzheimer’s Disease, Dementia, or other impairments, recommended patients take coconut oil to improve memory, and instructed certain patients to see her every 3-6 weeks for the rest of their lives. The Jenkinses billed Cognitive Center patients and health care benefits programs using Dr. Oliver Jenkins’ billing number.

This case was investigated by the Federal Bureau of Investigation in Toledo, Ohio, the United States Department of Health and Human Services, Office of Inspector General in Cleveland, Ohio, the Ohio Attorney General’s Medicaid Fraud Control Unit, and the Ohio State Medical Board. The case is being prosecuted by Assistant U.S. Attorneys Brian McDonough and Robert Melching.

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FWA- Queens Man Sentenced To 121 Months In Prison For Laundering Millions Of Dollars Of Fraud And Hacking Schemes And Committing Bank Fraud

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Djonibek Rahmankulow stole $5.4M from you via your W-2 using a variety of scams, including one where lots of pharmacies and Medicaid patients teamed up with him. None of them said thank you.

 
 

Clipped from: https://www.justice.gov/usao-sdny/pr/queens-man-sentenced-121-months-prison-laundering-millions-dollars-fraud-and-hacking

Damian Williams, the United States Attorney for the Southern District of New York, announced that DJONIBEK RAHMANKULOV was sentenced today to 121 months in prison for laundering millions of dollars in criminal proceeds obtained from computer hacking, healthcare fraud, and Small Business Administration loan fraud, as well as operating an international unlicensed money transmitting business.  The defendant was convicted at trial on September 1, 2022, of money laundering conspiracy, bank fraud, and conspiracy to operate an unlicensed money transmitting business.  U.S. District Judge Ronnie Abrams imposed today’s sentence.

U.S. Attorney Damian Williams said: “Djonibek Rahmankulov laundered money for a living.  He exploited the financial system to launder millions of dollars from multiple fraudulent schemes and repeatedly lied to banks to operate his illegal enterprise.  Once caught — and even after he was convicted — the defendant continued to show that he believed he was above the law by threatening a witness and submitting false information to the Court.  Today’s sentence reflects that this Office will find and prosecute those who seek to abuse the U.S. financial system to launder dirty money.”

According to the superseding Indictment, evidence at trial, and statements made in Court:

Between 2017 and September 2020, RAHMANKULOV operated a network of shell companies that were used to launder millions of dollars of criminal proceeds from multiple types of criminal activity.  RAHMANKULOV worked with computer hackers who fraudulently gained control of the bank accounts of victims located throughout the United States and executed millions of dollars in fraudulent wire transfers into bank accounts opened by RAHMANKULOV and his co-conspirators.  RAHMANKULOV received wire transfers into bank accounts he created and bank accounts he instructed others to create and laundered these proceeds through multiple additional bank accounts to prevent the victims and the banks from recovering the stolen funds.

In addition, RAHMANKULOV worked with a network of pharmacies engaged in Medicare and Medicaid fraud.  These pharmacies submitted millions of dollars of fraudulent billing for HIV medications that they did not dispense or obtained illegally, including by repurchasing medications from HIV patients who were Medicaid recipients.  RAHMANKULOV created companies to receive these criminal proceeds from the pharmacies and laundered them through a variety of means, including by using them to fund an unlicensed money transmitting business that illegally moved money to and from multiple countries, including Iran.

In 2020, when the COVID-19 pandemic began, RAHMANKULOV filed fraudulent applications for COVID relief loans from the Small Business Administration for multiple companies he controlled.  He laundered the proceeds of loans and grants through these companies.  RAHMANKULOV also made a number of materially false statements to financial institutions in connection with his money laundering schemes, both when opening bank accounts and when executing financial transactions with those bank accounts.

RAHMANKULOV sought to obstruct justice during the pendency of his case.  In the months before trial, RAHMANKULOV instructed a witness to lie to law enforcement.  When the witness later informed RAHMANKULOV that the witness would tell the truth to law enforcement, RAHMANKULOV threatened the witness, stating, among other things, that if he went to prison, “I will drag all of you with me, and once you are there, then I will have my revenge.”  Nonetheless, the witness testified at trial.  RAHMANKULOV continued seeking to obstruct justice after his conviction.  In advance of his sentencing, he submitted multiple letters to the Court purporting to show support from members of the community, but two of these letters were in fact fraudulent and had not been written by the purported authors.

*                *                *

In addition to the prison term, RAHMANKULOV, 35, of Queens, New York, was sentenced to three years of supervised release.  RAHMANKULOV was further ordered to pay a forfeiture of $5,413,278 and a $40,000 fine.

Mr. Williams praised the outstanding investigative work of the Federal Bureau of Investigation’s New York Money Laundering Investigation Squad.

The prosecution is being handled by the Office’s Money Laundering and Transnational Criminal Enterprises Unit.  Assistant U.S. Attorneys Cecilia Vogel, Thane Rehn, and Samuel Raymond, with the assistance of Paralegal Specialist Nerlande Pierre, are in charge of the prosecution.

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FWA- Man Pleads Guilty to $1.9M Baby Formula Fraud Scheme

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Vladislav Kotlyar stole $1.9M from you via your W-2 using a scam that forged prescriptions for specialty baby formula during that national formula crisis that seems forever ago. He did not say thank you.

 
 

 
 

Clipped from: https://www.justice.gov/opa/pr/man-pleads-guilty-19m-baby-formula-fraud-scheme

A New York man pleaded guilty today to defrauding insurance plans and medical suppliers by fraudulently procuring specialty baby formula. 

According to court documents, Vladislav Kotlyar, 43, of Staten Island, submitted and caused the submission of forged prescriptions and medical records for specialty baby formula that was paid for by health insurers. Kotlyar obtained prescriptions and medical records for infants who were prescribed specialty baby formula and forged those records to obtain additional specialty baby formula. After receiving the specialty baby formula, Kotlyar fabricated issues with the shipments, including by falsely claiming they were damaged or the incorrect formula to acquire additional formula at no additional cost. Kotlyar then sold the fraudulently obtained formula. As part of the scheme, Kotlyar and his co-conspirators submitted more than $1.9 million in fraudulent claims to health insurers, including during a national shortage of baby formula. Kotlyar agreed to forfeit approximately $1 million and repay more than $738,000 in restitution. 

Kotlyar pleaded guilty to mail fraud and faces a maximum penalty of 20 years in prison. A sentencing date has not been set. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

Assistant Attorney General Kenneth A. Polite, Jr. of the Justice Department’s Criminal Division, U.S. Attorney Breon Peace for the Eastern District of New York, and Assistant Director in Charge Michael J. Driscoll of the FBI New York Field Office made the announcement.

The FBI is investigating the case.

Trial Attorney Patrick J. Campbell of the Criminal Division’s Fraud Section is prosecuting the case.

The Fraud Section leads the Criminal Division’s efforts to combat health care fraud through the Health Care Fraud Strike Force Program. Since March 2007, this program, comprised of 15 strike forces operating in 25 federal districts, has charged more than 5,000 defendants who collectively have billed federal health care programs and private insurers more than $24 billion. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at https://www.justice.gov/criminal-fraud/health-care-fraud-unit.

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FWA- Massachusetts officials find $2.7 million fraudulently obtained SNAP, TAFDC, EAEDC benefits

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A tidy tally of how much fraud the MA OIG found in the last 90 days of 2022.

 
 

Clipped from: https://www.newbedfordguide.com/massachusetts-27-million-fraudulently-obtained-snap-tafdc-eaedc-benefits/2023/03/16

 
 

By Michael P. Norton.

Investigators in the state auditor’s office looked into 1,135 cases of suspected public benefits fraud over the last three months of 2022 and identified fraud in 255 of those cases totaling $2.7 million, according to Auditor Diana DiZoglio.

The auditor last month filed a report with the Legislature outlining the recent work of the Bureau of Special Investigations, which occurred while Suzanne Bump, DiZoglio’s predecessor, was finishing out her term.

During the last quarter of 2022, investigators found $1.6 million in Transitional Aid to Families with Dependent Children program (TAFDC) fraud, $771,000 in Supplemental Nutrition Assistance Program (SNAP) fraud, $283,000 in Medicaid fraud, and $7,300 in Emergency Aid to the Elderly, Disabled and Children (EAEDC) fraud.

The bureau detected $13.5 million in fraud in fiscal 2022, and $6 million in fiscal 2021. Gov. Maura Healey has proposed a big increase in the BSI budget, recommending a $2.92 million fiscal 2024 appropriation, up from projected spending of $2.01 million this fiscal year.

The bureau’s investigative authority extends to programs administered by the Department of Transitional Assistance, the Department of Children and Families, and the Division of Medical Assistance, which administers the massive MassHealth insurance program. The Department of Early Education and Care is not included in the BSI statute, but the bureau also works with that department through a memorandum of understanding.

BSI investigations can lead to fraud cases being referred to agencies for administrative action and fraudulent overpayments may be recovered through civil agreements. Individuals found to have committed fraud may be disqualified from programs, and cases may be referred for prosecution as well.”