Posted on January 29, 2021February 3, 2021 by MM_ADMIN

Maryland Woman Sentenced for Committing Health Care Fraud Government Continues Crackdown on People Who Defraud Medicaid | USAO-DC | Department of Justice

MM Summary- A Maryland woman stole $250,000 from D.C. Medicaid by submitting false timesheets for home care services.

WASHINGTON – Janet Olatimbo Akindipe, 62, of Laurel, Maryland, was sentenced today to 13 months in prison for defrauding the D.C. Medicaid program out of more than a quarter million dollars.

The announcement was made by Acting U.S. Attorney Michael R. Sherwin; James A. Dawson, Special Agent in Charge, FBI Washington Field Office, Criminal Division; Maureen R. Dixon, Special Agent in Charge of the U.S. Department of Health and Human Services’ Office of Inspector General for the region that includes Washington, D.C.; and Daniel W. Lucas, Inspector General for the District of Columbia.

At various times between November 2014 and June 2020, Akindipe was employed by six different home health agencies to serve as a personal care aide for D.C. Medicaid beneficiaries. The home health agencies employed Akindipe to assist Medicaid beneficiaries in performing activities of daily living, such as getting in and out of bed, bathing, dressing, and eating. Akindipe was supposed to document the care she provided to the Medicaid beneficiaries on timesheets and then submit the timesheets to the home health agencies, which would in turn bill Medicaid for the services that she rendered.

Between January 2015 and June 2020, Akindipe caused the D.C. Medicaid Program to issue payments totaling $269,808 for services that she did not render. As part of her fraud scheme, she submitted false timesheets to different home health agencies purporting that she provided personal care aide services that she did not provide. She claimed she provided such services during times when she actually was working her shift as a full-time employee at the National Institutes of Health. She claimed to work more than twenty hours in a given day on more than 300 occasions. She also claimed to provide personal care aide services in the District of Columbia on days when she was not even in the United States. As part of her fraud scheme, she paid kickbacks to get Medicaid beneficiaries to sign falsified timesheets.

In addition to sentencing Akindipe to 13 months in prison, she was also ordered to serve three years of supervised release and pay restitution in the amount of $269,808 and a forfeiture money judgment for $119,773.

The FBI, the Department of Health and Human Services’ Office of Inspector General, the District of Columbia’s Office of the Inspector General’s Medicaid Fraud Control Unit, and the U.S. Attorney’s Office are committed to investigating and prosecuting individuals who defraud the D.C. Medicaid program. Since October 2019, six former personal care aides, including Akindipe, have been sentenced in U.S. District Court for defrauding Medicaid. A seventh former personal care aide is expected to plead guilty. Cases against two other personal care aides remain outstanding.

The government counts on the public for tips and assistance in helping stop health care fraud. If you have information about individuals committing health care fraud, please call the Department of Health and Human Services’ Office of Inspector General hotline at (800) HHSTIPS [(800) 447-8477].

Assistant U.S. Attorney Kondi Kleinman of the Fraud Section prosecuted the case.

Clipped from: https://www.justice.gov/usao-dc/pr/maryland-woman-sentenced-committing-health-care-fraud-government-continues-crackdown

Posted on January 29, 2021February 3, 2021 by MM_ADMIN

Former Great Kills couple agree to fork over $$$ to resolve welfare-fraud case – silive.com

MM Summary – A NY couple hid their income so they could get SNAP benefits and stole $17,000.00

STATEN ISLAND, N.Y. — A couple formerly from Great Kills accused of welfare fraud is on the hook for over $17,000 in restitution after reaching a plea agreement with prosecutors.

But Yousef Shihadeh and Rihana Musleh would avoid jail if they pony up the cash.

The defendants carried out the scheme between January 2012 and September 2015, an indictment said.

The couple was living on the 100 block of Sandalwood Drive then, said a criminal complaint.

They resided in New Springville when arrested in March 2019, police said.

The complaint said Musleh submitted documents containing false information to obtain Medicaid and Supplemental Nutrition Assistance Program (SNAP) benefits.

SNAP benefits were previously known as food stamps.

Musleh failed to report Shihadeh’s income and financial resources to secure the benefits, said the complaint.

Shihadeh, 51, and Musleh, 43, were accused of grand larceny, welfare fraud and offering a false instrument for filing.

Shihadeh pleaded guilty on Tuesday in state Supreme Court, St. George, to a felony count of offering a false instrument for filing.

Musleh pleaded guilty to felony and misdemeanor counts of that charge.

Under their agreements, the defendants must fork over $17,139 to the city Human Resources Administration.

If they pay up by Aug. 1, 2022, the felony charge against Musleh will be vacated, and she’ll be sentenced to a conditional discharge on the misdemeanor conviction.

Shihadeh would also be sentenced to a conditional discharge, but on the felony conviction.

The couple potentially faced up to 28 months to seven years in prison had they gone to trial and been convicted of the top grand-larceny or welfare-fraud charge.

Biju Koshy, Musleh’s lawyer, declined comment on the case.

Matthew Santamauro, Shihadeh’s attorney, could not immediately be reached for comment.

Assistant District Attorney Joshua Freeman is prosecuting the case.

Clipped from: https://www.silive.com/crime/2021/01/former-great-kills-couple-agree-to-fork-over-to-resolve-welfare-fraud-case.html

Posted on January 29, 2021February 3, 2021 by MM_ADMIN

Compounding Pharmacy Mogul Sentenced for Multimillion-Dollar Health Care Fraud Scheme

MM Summary- A Mississippi man stole $287M from Tri-Care using his compounding pharmacy scheme to get paid for prescriptions that were not medically necessary. He also paid doctors kickbacks to participate in the scheme.

A Mississippi businessman was sentenced today for his role in a multimillion-dollar scheme to defraud TRICARE, the health care benefit program serving U.S. military, veterans, and their respective family members, as well as private health care benefit programs.

Wade Ashley Walters, 54, of Hattiesburg, a co-owner of numerous compounding pharmacies and pharmaceutical distributors, was sentenced today on his guilty plea to one count of conspiracy to commit health care fraud and one count of conspiracy to commit money laundering. U.S. District Judge Keith Starrett of the Southern District of Mississippi ordered Walters to serve a total of 18 years in prison and to pay $287,659,569 in restitution. Walters was remanded into custody following the sentencing hearing. Walters was further ordered to forfeit $56,565,963, representing the proceeds he personally derived from the fraud scheme.

“The fraud committed by Walters and others in this investigation wasted hundreds of millions of taxpayer dollars and deprived individuals of needed medical care,” said David P. Burns, Acting Assistant Attorney General of the Justice Department’s Criminal Division. “Today’s significant sentence signifies that we will continue to stand with our agency partners to root out health care fraud schemes and see their perpetrators brought to justice.”

Between 2012 and 2016, Walters orchestrated a scheme to defraud TRICARE and other health care benefit programs by distributing compounded medications that were not medically necessary. As part of the scheme, Walters and his co-conspirators, among other things, adjusted prescription formulas to ensure the highest reimbursement without regard to efficacy; solicited recruiters to procure prescriptions for high-margin compounded medications and paid those recruiters commissions based on the percentage of the reimbursements paid by pharmacy benefit managers and health care benefit programs, including commissions on claims reimbursed by TRICARE; solicited (and at times paying kickbacks to) practitioners to authorize prescriptions for high-margin compounded medications; routinely and systematically waived and/or reduced copayments to be paid by beneficiaries and members, including utilizing a purported copayment assistance program to falsely make it appear as if the pharmacies were collecting copayments.

“Today’s sentencing is another mile marker on the long road to justice for victims, our veterans, our military, and all American taxpayers, as the mastermind of the largest healthcare fraud scheme in Mississippi history has been held to answer for his crimes,” said Mike Hurst, U.S. Attorney for the Southern District of Mississippi. “I want to commend our prosecutors, Justice Department trial attorneys, and every member of this incredible team of federal, state, and local law enforcement agencies for discovering this scheme and bringing all of these criminals to justice. While there is more work to do, the public can rest assured that we will continue to hold evildoers to account and that justice will always be done in the Southern District of Mississippi.”

“This scheme to defraud TRICARE out of hundreds of millions of dollars not only diverted taxpayer money from essential services and medical care but victimized the brave men and women who selflessly serve or have served our country,” said Michelle Sutphin, Special Agent in Charge of the FBI’s Jackson Field Office. “The investigation into this specific scheme, which now spans across multiple states and FBI field offices, began in the FBI’s Jackson Field Office. I am incredibly proud of the relentless efforts made by our Special Agents, Intelligence Analysts and professional support staff, but also the assistance from our partner agencies which make cases like this successful. The FBI and our law enforcement partners are committed to seeking those that intend to steal from others for their own financial gain.”

“IRS Criminal Investigation provides financial investigative expertise in our work with our law enforcement partners, said James E. Dorsey, Special Agent in Charge of IRS Criminal Investigation (CI), Atlanta Field Office. “Pooling the skills of each agency makes a formidable team as we investigate allegations of wrong-doing. Today’s sentencing demonstrates our collective efforts to successfully enforce the law and ensure public trust.”

“The Defense Health Agency (DHA) works to set the standard in care for our military, families and veterans,” said Cyndy Bruce, Special Agent in Charge with the Defense Criminal Investigative Service (DCIS), Southeast Field Office. “With full knowledge, Mr. Walters aggressively exploited DHA for personal enrichment. I want thank the U.S. Department of Justice and our investigative team for their tireless work to bring these crimes to light. There is no victimless crime, these significant funds were stolen from each and every tax payer and I am pleased that today, this defendant is being held accountable for his actions.”

“The sentencing of Walters highlights continued cooperation among law enforcement agencies at the local, state, and federal levels to ensure public safety throughout Mississippi,” said Colonel Steven Maxwell, Director of the Mississippi Bureau of Narcotics (MBN). “Protecting the public from individuals like Walters is a priority for MBN and is a mainstay in accomplishing our agency’s mission.”

Walters and his numerous co-conspirators effectuated a scheme to defraud health care benefit programs, including the TRICARE program, in an amount exceeding $287 million. Walters further conspired with others to launder the proceeds of his fraud scheme by engaging in monetary transactions in amounts of over $10,000 in proceeds from the fraud scheme, including transactions relating to his participation in a sham intellectual property scheme.

The FBI’s Jackson Field Office investigated the case with assistance from the IRS-CI, DCIS, and MBN. Principal Assistant Deputy Chief Dustin M. Davis, Assistant Deputy Chief Katherine E. Payerle, and Trial Attorney Sara E. Porter of the Criminal Division’s Fraud Section, Trial Attorneys Emily Cohen and Steven Brantley of the Criminal Division’s Money Laundering and Asset Recovery Section, and Assistant U.S. Attorney Kathlyn R. Van Buskirk of the Southern District of Mississippi are prosecuting the case.

The Fraud Section leads the Health Care Fraud Strike Force. Since its inception in March 2007, the Health Care Fraud Strike Force, which maintains 15 strike forces operating in 24 districts, has charged more than 4,200 defendants who have collectively billed the Medicare program for approximately $19 billion. In addition, the Health and Human Services (HHS) Centers for Medicare & Medicaid Services, working in conjunction with the HHS-Office of Inspector General, are taking steps to increase accountability and decrease the presence of fraudulent providers.

Clipped from: https://www.justice.gov/opa/pr/compounding-pharmacy-mogul-sentenced-multimillion-dollar-health-care-fraud-scheme

Posted on January 29, 2021January 29, 2021 by MM_ADMIN

Texas man stole $664k from Medicare and Medicaid using bogus ambulance claims

MM Summary- A TX man submitted fake claims for ambulance services that were not provided and stole $664,000 from Medicare and Medicaid.

On January 8, Christopher Reed Freed, 46, was sentenced to 5 years in prison and ordered to pay $244,029.68 in restitution for health care fraud. Freed operated an ambulance service provider located in the Northern District. Freed sought to obtain payment from Medicare for non-emergency ambulance services. As part of the scheme, Freed submitted 754 fraudulent claims to Medicare totaling approximately $664,640. These submitted claims were materially false in that they were for services that were not rendered by Freed. This case was investigated by Health and Human Services – OIG and the Texas OAG Medicaid Fraud Control Unit. Assistant U.S. Attorney Matthew Smid prosecuted this case.

Clipped from: https://www.justice.gov/usao-ndtx/pr/ndtx-round-january-8-14

Posted on January 29, 2021January 29, 2021 by MM_ADMIN

Former government employee charged with embezzlement, fraud

MM Summary- A Virginia state employee falsified her own Medicaid application and received $1,800 of medical services.

A former Medicaid eligibility supervisor for the V.I. Human Services Department was charged Friday with lying on government forms to obtain Medicaid benefits that she was not eligible to receive, according to the warrant for her arrest.

Kathleen Gussie was charged with embezzlement by a public or private officer, embezzlement or falsification of public accounts, conversion of government property, and three counts of making fraudulent claims upon the government. She was released after posting 10% of $50,000 bond, and is scheduled to appear in court Monday.

V.I. Attorney General Denise George held a press conference Friday, when she praised the Justice Department’s newest division, the Medicaid Fraud Control Unit, for acting on a case that had been sitting untouched for years.

It’s unclear why prosecutors did not pursue the case sooner, but according to the affidavit filed by Special Agent Gisselle Quinones, who is in charge of the Special Investigations Division, the suspected fraud was first reported in February 2018. At that time, another Medicaid eligibility supervisor was reviewing “error reports” to identify suspicious entries and came across “what appeared to be fraudulent activities connected with entries in the name of Gussie,” according to the affidavit.

Gussie went to Luis Hospital emergency room on Dec. 11, 2017, and submitted a “Hospital Presumptive Eligibility,” or “HPE” application for Medicaid benefits that listed her income as $30,000.

The income threshold to determine eligibility for Medicaid benefits at the time was $31,931 per household, but Gussie’s actual salary was $44,103, and government documents show that she “was aware of her salary” and “should have known that she was not eligible for Medicaid benefits,” according to the affidavit.

Gussie was deemed eligible for temporary benefits from Dec. 11, 2017, through Jan. 31, 2018, and subsequently enrolled as a permanent Medicaid beneficiary. Gussie continued submitting claims for payment by various medical providers up until July 3, 2018, according to the affidavit. “At no time did Gussie notify the Medicaid program, of which she was a supervisor, that income information provided on her HPE application and in her permanent application for benefits was in error and request that the necessary correction be made. Had that notification been done, Gussie would not have qualified for Medicaid benefits.”

Between June 2007 and April 2016 Gussie worked in various capacities throughout the Medicaid division, and even helped edit the department’s “Manual for the Determination of Medicaid Eligibility,” according to the affidavit.

On Feb. 22, 2018, then-Human Services commissioner Felicia Blyden notified Gussie she was being placed on administrative leave pending an investigation into allegations she violated Medicaid eligibility procedures by applying for benefits during the emergency room visit.

At an administrative hearing on April 11, 2018, “it was recommended that Gussie be terminated from her employment for defrauding the Medicaid Program,” according to the affidavit. “A letter dated April 18, 2018 addressed to Gussie officially notified her of the DHS’s recommendation for her immediate termination.”

But “Gussie did not request that her benefits be cancelled and continued to allow the fraud to continue for months,” according to the affidavit. Despite the recommendation that she be fired immediately, Gussie remained employed but under suspension for a further three years.

“She was on suspension for quite some time. Just recently, several months ago, she was then terminated, finally, with the approval of this governor, Gov. Bryan,” George said Friday.

A total of 35 medical claims were submitted by various providers for services totaling $485.85, and the emergency room visit cost Luis Hospital $1,478.43, according to the affidavit.

The claim for services was initially submitted for payment to Medicaid, but as an employee of the Virgin Islands government, Gussie’s primary insurance was CIGNA.

“Therefore, the claim was rejected for payment by the Medicaid Program. Subsequently, CIGNA paid the amount covered by the CIGNA plan,” according to the affidavit. The remaining balance of $1,478.43 “was again re-submitted for payment to the Medicaid Program; at which time it was determined that the claim was not processed in a timely manner and the claim was denied.”

Clipped from: http://www.virginislandsdailynews.com/news/former-government-employee-charged-with-embezzlement-fraud/article_e60b6986-1bfd-55ba-a290-e0e1df0f0adf.html

Posted on January 29, 2021January 29, 2021 by MM_ADMIN

Marlboro fraud: Man admits bribing doctors, defrauding IRS of $9.1 million

Curator summary – Alex Fleyshmakher (Bronx) operated a kickback scheme where he paid doctors to send patients to his pharmacies and got $25M in payments from Medicare and Medicaid.

A Marlboro man pleaded guilty on Thursday in federal court to paying kickbacks to doctors and their staff so they would send their patients to his family’s pharmacy and then concealed the activity from the IRS, Acting U.S. Attorney Rachael A. Honig announced.

Alex Fleyshmakher, 34, of the Morganville section, was charged in the U.S. District Court in Trenton with conspiring to violate the federal anti-kickback statute and conspiring to defraud the IRS of $9.1 million in federal taxes, according to a written statement from the U.S. Attorney’s Office.

Fleyshmakher worked at a pharmacy chain called Prime Aid. He worked at its store in Union City, which was co-owned by his father, Igor Fleyshmakher. The younger Fleyshmakher was himself an owner of Prime Aid Bronx — at least on paper. The pharmacy chain specialized in expensive medications that are used to treat such conditions as Hepatitis C, Crohn’s disease, and rheumatoid arthritis, the statement said.

From 2008 and 2017, Fleyshamkher and other Prime Aid employees paid kickbacks and bribes to doctors and their employees in New Jersey and New York. Those kickbacks and bribes included expensive meals, designer bags, cash payments, check payments and money wire transfers, according to the statement.

The prescriptions processed at Prime Aid Union City from one New Jersey medical practice resulted in $24.8 million in Medicare and Medicaid payouts, the statement said.

From 2011 to 2018, Alex Fleyshmakher, working with others, “surreptitiously took insurance reimbursement checks” totaling millions of dollars from the Prime Aid Pharmacies, the statement said.

“Aided by his conspirators, Alex Fleyshmakher then cashed the checks at Brooklyn check cashing businesses or diverted them through Canadian bank accounts back into U.S. accounts that he owned and controlled. He concealed these funds and failed to report them on his personal income tax returns, resulting in a $9.1 million tax loss to the IRS,” the statement said.

The conspiracy and tax evasion charges to which Alex Fleyshmakher pleaded guilty each carries a maximum sentence of five years in federal prison and a $250,000 fine. A sentencing date has been scheduled for May 27, the statement said.

Other alleged conspirators in the kickback scheme included his father, Igor Fleyshmakher of Holmdel, who previously pleaded guilty for his role in the conspiracy; and Eduard “Eddy” Shtindler, of Paramus, who also previously pleaded guilty in a related kickback conspiracy. Their sentencing dates are also pending, the statement said.

Other defendants have also been charged in the matter.

The Prime Aid pharmacies in Union City and the Bronx are now closed, the statement said.

Fleyshmakher made his plea by videoconference Thursday before U.S. District Judge Michael A. Shipp in Trenton.

Honig credited special agents of the FBI, under the direction of Special Agent in Charge George M. Crouch Jr. in Newark; special agents of IRS-Criminal Investigation, under the direction of Special Agent in Charge Michael Montanez in Newark; special agents of the Department of Health and Human Services-Office of Inspector General, under the direction of Special Agent in Charge Scott J. Lampert; and the N.J. Office of the State Comptroller, under the direction of Acting Comptroller Kevin D. Walsh, with the investigation that resulted in Thursday’s guilty plea.

The government is represented by Assistant U.S. Attorney Joshua L. Haber of the Health Care Fraud Unit of the U.S. Attorney’s Office in Newark.

Newark-based defense attorney Henry Klingeman represents Fleyshmakher.

Clipped from: https://www.app.com/story/news/local/western-monmouth-county/marlboro/2021/01/14/marlboro-man-admits-bribing-doctors-and-defrauding-irs-family-pharmacy/4169593001/

Posted on January 29, 2021June 28, 2021 by MM_ADMIN

Medicaid Concepts: Jail Health

This is part of our Medicaid Concepts series, in which we try to provide a high level overview of key concepts in the Medicaid industry today.

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Topic overview

What do we mean by jail health?

In general this discussion includes both healthcare services while incarcerated and during the transition period once the individual leaves prison and returns to society. While incarcerated, there are a range of services and contractors who provide physical and mental health services to prisoners. When offenders exit prison, there are programs operated by health plans and states to assist in the transition.

What role does Medicaid play in this area?

Medicaid can cover services for inmates and returning offenders. Before the Affordable Care Act in 2014 (ACA) many states did not choose to provide services to inmates under Medicaid because they usually did not meet eligibility criteria (non-disabled adults without dependent children). ACA provided new funding via the “expansion” group category that made it easier for prisoners to be eligible while inside.

Many states follow CMS guidance on suspending (vs terminating) inmate coverage once they enter prison. This allows the state to more easily resume coverage once the offender returns (which is a critical time period of transition, with much higher changes of mortality and other negative outcomes). This also allows for Medicaid to cover off-site healthcare services such as inpatient stays, even when the inmate goes back to prison after the stay.

States that do cover eligible prisoners usually exclude them from managed care capitation arrangements (instead covering them under their fee for service program).

States and health plans continue to try and improve the healthcare services provided to incarcerated and returning members. For returning members, Medicaid programs and plans focus on provider coordination, job services and closing gaps related to social determinants of health.