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[MM Curator Summary]: Jonathan Sumter stole $1M using a fake behavioral health company that never actually had any clients or providers.

 
 

 
 

Clipped from: https://www.justice.gov/usao-sc/pr/greer-man-sentenced-multimillion-dollar-south-carolina-medicaid-scheme

Columbia, South Carolina – Jonathan W. Sumter, 51, of Greer, was sentenced to over 7 years in federal prison after pleading guilty in a case of theft of government funds for his scheme to defraud South Carolina Medicaid of over $1 million.

According to evidence presented to the Court, Sumter founded PHC Supportive Services as a company supposedly providing rehabilitative behavioral health services to disabled, low-income individuals in South Carolina through the Medicaid program. Instead, between 2015 and 2019, the company billed South Carolina Medicaid over one million dollars for services never performed.

The Government provided evidence that PHC never had any actual clients or service providers. Instead, Sumter repeatedly billed Medicaid by using the stolen National Provider Identifier (NPI) numbers of nine health care professionals to create fraudulent invoices to Medicaid. Sumter then used the stolen identities of 196 Medicaid members with severe mental and emotional health disorders without their knowledge or consent. Caregivers and clients contacted by investigators indicated that they had never received any services from Sumter or PHC. Additionally, the service providers Sumter used on his invoices indicated that they did not work for PHC and had not provided medical services for the company.

“Using stolen identifies of the most defenseless people to steal money from the hard-working people of South Carolina is unacceptable. We will continue to aggressively prosecute offenders who steal from programs designed to provide sorely needed care for our most vulnerable citizens,” said U.S. Attorney Adair Boroughs.

“This sentence warns bad actors in the behavioral healthcare field that South Carolina has citizens in need of these services; any fraudulent conduct that abuses these programs or prevents our citizens from receiving needed services will not be tolerated. Our office will continue to partner with the United States Attorney’s Office for the arrest and prosecution of those committing fraud against the Medicaid program. We thank our law enforcement partners at the United States Department of Health and Human Services’ Office of the Inspector General for their partnership during this investigation,”  Attorney General Alan Wilson said.

United States District Judge Donald C. Coggins sentenced Sumter to 92 months in prison. Sumter was also ordered to repay $1,055,373.66 in restitution to South Carolina Medicaid.

The case was investigated by the United States Department of Health and Human Services and the South Carolina Attorney General’s Office. It was prosecuted by Assistant United States Attorney T. DeWayne Pearson.

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[MM Curator Summary]: Hanna Mitias stole $1.9M by substituting cheap knee injection drugs for more expensive ones he billed for.

 
 

 
 

Clipped from: https://www.oxfordeagle.com/2023/01/11/mitias-to-pay-1-87-million-to-settle-allegations-of-medicare-and-medicaid-overbilling/

Published 4:30 pm Wednesday, January 11, 2023

By Staff Report

 
 

The Nothern Mississippi Department of Justice

Mitias Orthopaedics, PLLC, it’s owner Dr. Hanna “Johnny” Mitias, and a subsidiary Champion Orthopedics, have agreed to pay $1,870,714.83 to resolve allegations the orthopedic health services providers knowingly submitted false claims to Medicare and Medicaid, the Department of Justice announced today.

“Taxpayers deserve to receive the products and services billed to their federal health insurance programs.  The viability of Medicare and Medicaid is threatened by each wasted dollar. Our people come before profits,” said United States Attorney Clay Joyner.  “This settlement sends a clear message that the Department of Justice will hold healthcare providers accountable if they knowingly overbill federal healthcare programs.”

Between Jan. 1, 2008, and Dec. 31, 2015, Mitias and his clinics allegedly submitted false claims to the Medicare and Medicaid programs for brand name viscosupplementation agents for knee injections that were not administered to the beneficiaries of those programs.  Rather, a much cheaper, compounded viscosupplementation agent was alleged to have been used and, as a result, the defendants improperly claimed compensation for the higher priced products.

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“We are committed to thoroughly investigating claims of fraud and holding health care providers accountable when they break the rules. The public should know we will devote the necessary time and effort to stamp out healthcare fraud in both civil and criminal matters,” said Joyner.  “This settlement is an example of how whistleblowers and the government can work together to recoup and deter overbilling practices.”

The settlement resolves allegations in a 2015 lawsuit by a medical device sales representative filed under the whistleblower provisions of the False Claims Act.  Those provisions permit private individuals to sue on behalf of the government for false claims and to share in any recovery.

The settlement was the result of a coordinated effort by the Civil Division of the Department of Justice, the United States Attorney’s Office for the Northern District of Mississippi, the Department of Health & Human Services, Office of Inspector General, and the State of Mississippi Attorney General’s Office Medicaid Fraud Control Unit.

The case is captioned United States ex rel. Gray v. Mitias Orthopaedics, PLLC (3:15-cv-127). The claims resolved by the settlement are allegations only and there has been no determination of liability.

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MM Curator summary

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[MM Curator Summary]: John, Rob and Richard stole $44M using a kickback scheme to drive revenues for their genetic testing lab.

 
 

Clipped from: https://www.upi.com/Top_News/US/2023/01/06/justice-department-charges-fraud-medicare-medicaid/7701673039406/

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Jan. 6 (UPI) — Three men have been charged with conspiring to defraud the federal government out of more than $107 million after submitting fraudulent genetic testing claims to Medicare.

A superseding indictment was opened Friday, charging John Grisham and Rob Wilburn, of Texas, and Richard Speights Jr., of Louisiana, the Justice Department said in a release.

The three men allegedly owned and operated a genetic testing laboratory in Lewisville, Texas between January 2018 and October 2019.

They are accused of acquiring thousands of Medicare beneficiaries’ DNA specimens and corresponding prescriptions, which Trinity Clinical Laboratories then used to fraudulently bill Medicare and Medicare Advantage for genetic testing.

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The sophisticated and nationwide health care kickback scheme allegedly netted some $44 million worth of Medicare reimbursements “due to the defendants’ payment and receipt of kickbacks and bribes,” according to the Justice Department.

Following a multi-agency investigation, all three men are now facing one count of conspiracy to defraud the United States and to pay and receive kickbacks and bribes.

Additionally, Grisham, 49, and Wilburn, 51, are each charged with six counts, and Speights Jr.,52, is charged with two counts of paying and receiving health care kickbacks and bribes.

If convicted, the men face 10 years in prison on each count of paying and receiving health care kickbacks and bribes and five years incarceration on the conspiracy count.

The investigation came under the umbrella of the national Health Care Fraud Strike Force Program.

Since March 2007, the program has charged more than 4,200 defendants who collectively have billed the Medicare program for more than $19 billion.

In November, the Justice Department charged 10 individuals in multiple states for defrauding healthcare providers, insurance companies, Medicare and Medicaid.

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[MM Curator Summary]: Wafa Abboud used her non-profit to steal $1.4M by hiding monthly “consulting” payments to herself.

 
 

Clipped from: https://www.justice.gov/usao-edny/pr/former-executive-director-long-island-charity-sentenced-over-two-years-prison

Defendant and Co-Conspirators Used Multiple Schemes to Steal Over $1 Million from Non-Profit Agency Devoted to Assisting Developmentally Disabled Youth, Spending the Funds on Luxury Items

Earlier today, at the federal courthouse in Brooklyn, Senior United States District Judge Edward R. Korman sentenced Wafa Abboud to a term of imprisonment of 33 months.  As part of the sentence, Judge Korman also ordered Abboud to forfeit $836,000 and pay $1,415,000 in restitution to Human First, Inc. (Human First), the nonprofit agency that Abboud led for more than five years.  Abboud was convicted following a two-week jury trial in July 2019 of theft from programs receiving federal funds, bank fraud, and conspiracies to commit those crimes.  

Breon Peace, United States Attorney for the Eastern District of New York, announced the sentence.

“Stealing taxpayer money earmarked for developmentally disabled youth to pay for vacations, cosmetic surgery, and luxurious vacations is shameful,” stated United States Attorney Peace.  “Today, the defendant has been held accountable for betraying the most vulnerable among us whom she was entrusted to serve and treating the non-profit organization bank accounts as though they were her own.”

Mr. Peace thanked the Federal Bureau of Investigation, New York Field Office, for its investigative work on the case.

From January 2011 until her termination on May 27, 2016, Abboud was the Executive Director of Human First, a non-profit corporation that provided services to individuals with autism and other developmental disabilities. In that capacity, Abboud exercised nearly complete control over the charity’s finances.  During Abboud’s tenure, Human First received tens of millions of dollars annually from the New York State Office for People with Development Disabilities, which is funded in significant part by the Medicaid program.  The money was disbursed to Human First to support its mission of providing residential, rehabilitative, and other services to developmentally disabled youth. 

Abboud entered into an agreement with co-defendant Marcelle Bailey whereby Abboud caused Human First to pay Bailey’s company MPB Management Services LLC (MPB) approximately $16,000 per month in purported “consulting” fees.  Bailey deposited approximately half of each monthly disbursement into bank accounts that were controlled by Abboud, who used the money to fund a lavish lifestyle, including expensive international vacations, visits to luxury spas and high-end beauty salons and restaurants, and elective cosmetic surgeries.  Abboud also withdrew approximately $120,000 from the accounts in cash and wired tens of thousands of dollars in the account overseas. In total, Abboud stole approximately $420,000 between May 2011 and February 2016 through the MPB embezzlement scheme. 

Abboud also conspired with co-defendant Rami Taha to steal over $400,000 through a scheme in which Abboud deliberately issued overpayments to contractors performing work on Human First properties with the knowledge that the overpayment would be kicked back to her.  The overpayments were disguised through the use of inflated invoices submitted to Human First, and the payments to Abboud were hidden by transferring the funds through a number of sham bank accounts before ultimately depositing them into accounts controlled by Abboud.  Abboud used the stolen money to finance the down payment and renovation of her residence.  To conceal the true source of the funds, Abboud lied to her mortgage lender, falsely claiming that the funds were a settlement payment she had received for damage caused to her previous home. 

Bailey pleaded guilty to embezzlement and bank fraud in December 2017 and was sentenced by Judge Korman in August 2021 to 33 months in prison.  Taha pleaded guilty in May 2019 to embezzlement.  A fourth defendant, Arkadiusz Swiechowicz, pleaded guilty to obstruction of justice in September 2018.  Taha and Swiechowicz are awaiting sentencing. 

The government’s case is being handled by the Office’s Public Integrity Section.  Assistant United States Attorneys Robert Polemeni and Turner Buford are in charge of the prosecution.  Assistant United States Attorney Tanisha Payne of the Office’s Asset Recovery Section is handling forfeiture matters in the case. 

The Defendant:

WAFA ABBOUD
Age:  55
Merrick, NY

E.D.N.Y. Docket No. 16-CR-396 (ERK)

MM Curator summary

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[MM Curator Summary]: Phillips RS North America will pay $24M for its scam that paid DME companies kickbacks in the form of data that was valuable for marketing and sales.

 
 

Clipped from: https://news.delaware.gov/2023/01/11/delaware-to-receive-nearly-56000-for-alleged-false-claims-caused-by-respiratory-related-medical-equipment/

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Delaware has joined with other states and the federal government to reach an agreement in principle with Philips RS North America LLC, (formerly known as Respironics Inc.), a manufacturer of durable medical equipment (DME) based in Pittsburgh, Pennsylvania, to resolve federal False Claims Act and Delaware False Claims and Reporting Act (DFCRA) allegations that it misled federal health care programs by paying kickbacks to DME suppliers.

Respironics has agreed to pay over $24 million to resolve the allegations that affected Medicare, Medicaid and TRICARE, which is the health care program for active military and their families.  Of the total settlement amount, $4,826,250.00 will go to the Medicaid program.  Delaware’s Medicaid program will receive $55,688.54.

“Kickbacks result in improper claims being filed with Medicaid and other healthcare benefit programs, and drain precious resources that Medicaid recipients rely on,” Attorney General Jennings said.  “We will continue fighting against fraud, waste, and abuse against the government.”

The settlement resolves allegations that from November 1, 2014 through April 30, 2020, that Respironics caused DME suppliers to submit false claims to the Medicaid program for ventilators, oxygen concentrators, CPAP and BiPAP machines, and other respiratory-related medical equipment, when such claims were tainted by Respironics’ providing unlawful remuneration to these DME suppliers in the form of physician prescribing data (known as “HMS” or “Health Market Science data”), free of charge, knowing that this data may be of significant value to DME suppliers in their own marketing efforts.

This settlement arises from a qui tam action originally filed in October of 2019 and then amended in November of 2019 in the United States District Court for the District of South Carolina under the federal False Claims Act and various states’ statutes, including the DFCRA.

Delaware, along with representatives from the Offices of the Attorneys General for the states of Florida, Illinois, Indiana, New York, Pennsylvania, Tennessee, and Washington, assisted in leading a National Association of Medicaid Fraud Control Units (NAMFCU) team during the investigation and settlement negotiations with Respironics on behalf of the states.

The Attorney General’s Medicaid Fraud Control Unit receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $2,023,800 for Federal FY 2022. The remaining 25 percent, totaling $674,595 for FY 2022, is funded by Delaware.

 
 

 
 

 
 

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Delaware to Receive Nearly $56,000 for Alleged False Claims Caused by Respiratory-Related Medical Equipment

Featured Posts | News | Date Posted: Wednesday, January 11, 2023
 

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Delaware has joined with other states and the federal government to reach an agreement in principle with Philips RS North America LLC, (formerly known as Respironics Inc.), a manufacturer of durable medical equipment (DME) based in Pittsburgh, Pennsylvania, to resolve federal False Claims Act and Delaware False Claims and Reporting Act (DFCRA) allegations that it misled federal health care programs by paying kickbacks to DME suppliers.

Respironics has agreed to pay over $24 million to resolve the allegations that affected Medicare, Medicaid and TRICARE, which is the health care program for active military and their families.  Of the total settlement amount, $4,826,250.00 will go to the Medicaid program.  Delaware’s Medicaid program will receive $55,688.54.

“Kickbacks result in improper claims being filed with Medicaid and other healthcare benefit programs, and drain precious resources that Medicaid recipients rely on,” Attorney General Jennings said.  “We will continue fighting against fraud, waste, and abuse against the government.”

The settlement resolves allegations that from November 1, 2014 through April 30, 2020, that Respironics caused DME suppliers to submit false claims to the Medicaid program for ventilators, oxygen concentrators, CPAP and BiPAP machines, and other respiratory-related medical equipment, when such claims were tainted by Respironics’ providing unlawful remuneration to these DME suppliers in the form of physician prescribing data (known as “HMS” or “Health Market Science data”), free of charge, knowing that this data may be of significant value to DME suppliers in their own marketing efforts.

This settlement arises from a qui tam action originally filed in October of 2019 and then amended in November of 2019 in the United States District Court for the District of South Carolina under the federal False Claims Act and various states’ statutes, including the DFCRA.

Delaware, along with representatives from the Offices of the Attorneys General for the states of Florida, Illinois, Indiana, New York, Pennsylvania, Tennessee, and Washington, assisted in leading a National Association of Medicaid Fraud Control Units (NAMFCU) team during the investigation and settlement negotiations with Respironics on behalf of the states.

The Attorney General’s Medicaid Fraud Control Unit receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $2,023,800 for Federal FY 2022. The remaining 25 percent, totaling $674,595 for FY 2022, is funded by Delaware.

 
 

 
 

 
 

Keep up to date by receiving a daily digest email, around noon, of current news release posts from state agencies on news.delaware.gov.

Here you can subscribe to future news updates.

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[MM Curator Summary]: Stephanie, Quinetta and Bobby stole $134k claiming Quinetta was providing home health services while she was in jail.

 
 

 
 

Clipped from: https://www.denver7.com/news/local-news/3-colorado-woman-charged-in-medicaid-scheme-claiming-inmate-was-providing-in-home-care

 
 

DENVER — Three Colorado women were charged in an alleged Medicaid fraud scheme in which they claimed one provided home healthcare services to the others from prison. The total value of the theft is $134,235.25, according to the Colorado Attorney General’s Office.

Attorney General Phil Weiser today announced Monday that all three suspects — Stephanie Hudgins, 50, Quinetta Hunter, 40, and Bobby Hunter, 68 — were charged with several felony counts, including violation of the Colorado Organized Crime Control Act, money laundering, theft, and forgery.

According to Weiser, the alleged fraud occurred between Aug. 1, 2020, and June 6, 2022, when Quinetta Hunter was in custody at the La Vista Correctional Facility in Pueblo. The charges allege Hudgins and Bobby Hunter filed claims and received Medicaid reimbursement for home care services that did not occur.

Hudgins and Bobby Hunter claimed that Quinetta Hunter provided those services, but she was, and remains, in the custody of the Colorado Department of Corrections, according to a news release from the Colorado Attorney General’s Office.

Quinetta Hunter had previously worked for a Northglenn-based home care business that provided Medicaid-funded home services to patients.

All three suspects “worked together to submit falsified work timesheets and cash checks under Quinetta Hunter’s name, and then to pocket money paid by the business out of Colorado Medicaid funds,” the release read.

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[MM Curator Summary]: Richard Reid ran a kickback scheme that stole $6.5M for two labs.

 
 

Clipped from: https://www.justice.gov/usao-wdwa/pr/former-co-owner-and-sales-manager-defunct-medical-testing-lab-sentenced-prison

Illegally profited from kick-backs for referring government funded lab testing business

Seattle – A resident of Astoria, Oregon was sentenced today in U.S. District Court in Seattle to two years in prison for five federal felonies connected to his scheme to profit from illegal kickbacks in the medical testing industry, announced U.S. Attorney Nick Brown.  Richard Reid, 53, was convicted in March 2022, following a six-day jury trial.  At today’s sentencing hearing, U.S. District Judge John C. Coughenour denied a defense motion to postpone the prison sentence while Reid appeals his conviction.

“Mr. Reid was the architect of a scheme to illegally profit on toxicology tests that were paid for by government insurance,” said U.S. Attorney Brown. “The web of referrals and kick-backs led to significant profits for NWPL and its owners.  Such illegal kick-backs simply inflate medical costs for the rest of us.”

The activities of Bellevue-based Northwest Physicians Laboratory (NWPL) have been the subject of extensive civil and criminal litigation.  Richard Reid was one of the owners and the Vice President of Sales for NWPL.  Reid helped NWPL obtain more than $3.7 million in kickback payments by steering urine drug test specimens to two labs that could bill the government for testing. This resulted in government payments to those two labs of more than $6.5 million.

According to records filed in the case between January 2013 and July 2015, two labs, that were not physician owned, made payments to NWPL in exchange for referrals of Medicare and TRICARE program business, in violation of the Anti-Kickback Statute.  Paying remuneration to medical providers or provider-owned laboratories in exchange for referrals encourages providers to order medically unnecessary services.  The Anti-Kickback Statute functions, in part, to discourage such behavior. NWPL was physician-owned, and for that reason could not test urine samples for patients covered by government health programs such as Medicare, Medicaid, and TRICARE.  In order to conceal the payment of the kickbacks, Reid and other co-conspirators involved described the fees as being for marketing services; however, no marketing services were performed. 

In the sentencing memo asking that Reid receive the same two-year sentence as CEO Jae Lee, prosecutors described his role writing, “Reid hid the truth and kept the cover story in place by lying to his sales force, lying to providers, and sharing fraudulent opinion letters from attorneys.  NWPL grew and the money – including illegal kickbacks – rolled in.  The kickbacks increased as time went on, and totaled almost $5 million.  As the proceeds of the crime rose, so did Reid’s monthly distributions — from $10,000 in 2013 to $50,000 in 2015.” 

Reid was convicted of one count of conspiracy to solicit and receive kickbacks involving health care programs and four counts of receipt of kickbacks.

The company, NWPL, pleaded guilty in February 2021 and was sentenced to pay $8,114,417 in restitution joint and several with the other criminal defendants.  NWPL has dissolved. To date, the labs and individuals involved in this investigation have paid more than $14 million to settle related civil allegations. 

In addition to Reid, three other defendants have pleaded guilty and await sentencing.  Former NWPL CEO Jae Lee was sentenced to two years in prison in May 2022.  Kevin Puls, the former Executive Director of NWPL was sentenced to 90 days in prison and a year of supervised release.

“Mr. Reid’s sentencing culminates his part in a years-long investigation wherein he was convicted last year for actively orchestrating and personally benefiting from a scheme to corrupt and defraud the healthcare system, including the Department of Defense’s TRICARE program,” said Bryan D. Denny, the Special Agent in Charge of the DoD Office of Inspector General, Defense Criminal Investigative Service (DCIS), Western Field Office.  “DCIS will continue to work with its partners to root out fraudulent activities, like those in this particular investigation, that weaken TRICARE and inevitably increase costs unnecessarily.”

“Mr. Reid let his greed get in the way of doing what was right by taxpayers” said Richard A. Collodi, Special Agent in Charge of the FBI’s Seattle field office. “He solicited and received hundreds of thousands of dollars in kickbacks. Ultimately, frauds like these inflate health care costs for the rest of us. I applaud the work of our investigators and partners to hold Mr. Reid accountable, provide justice to the victims, and bring his crimes to an end.”

The case was investigated by the FBI, Health and Human Services Office of Inspector General (HHS-OIG), and the Defense Criminal Investigative Service (DCIS).

The case was prosecuted by Assistant United States Attorney Michael Dion and former Assistant United States Attorney Brian Werner.