Tag: Fraud

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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]: One of the 78 people caught in the national Medicaid fraud dragnet that uncovered $2.5B in fraud.

 
 

 
 

Clipped from: https://www.localnewsdigital.com/2023/06/30/attorney-generals-office-investigates-health-care-fraud/

 
 

Courtesy – DOJ.

INDIANAPOLIS – The Indiana Attorney General’s office, through its Medicaid Fraud Control Unit, joined more than a dozen states and the federal government Wednesday in a nationwide enforcement action against 78 individuals charged with $2.5 billion in Medicaid Fraud. One of those charged is a licensed practice nurse (LPN) in Columbus.

Columbus LPN Erin McMillan, 44, faces charges of obtaining a controlled substance by fraud; furnishing false or fraudulent information; and failure to make, keep, or furnish a record. Complaint filings reportedly include video footage of McMillan obtaining narcotic medications but not administering them and staff alleging that she put items into her personal bags at work, per the Attorney General’s office.

According to the U.S. Department of Justice, defendants supposedly defrauded Medicaid and Medicare programs and some used the proceeds to buy exotic automobiles, jewelry, and yachts. The Justice Department seized millions in cash, automobiles, and real estate related to the schemes.

The Indiana Attorney General’s Office investigated eight cases against licensed healthcare professionals and medical offices. Department attorneys, with the assent of local prosecutors, will pursue charges against the accused.

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[MM Curator Summary]: “Marketers” and the parents/caregivers of Medicaid kids took kickbacks to help facilitate this dental services scheme.

 
 

 
 

Clipped from: https://www.texasattorneygeneral.gov/news/releases/texas-attorney-generals-medicaid-fraud-control-unit-helps-take-down-69-million-medicaid-fraud-scheme

Christian Agno Aquino, 42, of Humble, was arrested for his role in a $6.9 million Medicaid fraud and kickback scheme, alongside Rene Gaviola, 67, and Ifeanyi Ndubisi Ozoh, 51, of Houston, who were previously arrested. The defendants are charged with defrauding the Medicaid program through illicit practices committed through the Floss Family Dental Care clinic in Houston. 

According to the indictment, Gaviola, the operator of Floss Family Dental Care, together with his managers Ozoh and Aquino, submitted fraudulent claims to Medicaid for pediatric dental services that were not provided or were in some cases performed by unlicensed individuals. The defendants are also accused of offering illegal kickbacks to marketers and caregivers of Medicaid-insured children, enticing them to bring the children to Floss for fraudulent dental services. 

The indictment also details how Gaviola laundered Medicaid funds, transferring them from the Floss business bank account to his personal account in transactions exceeding $100,000. From 2019 to 2021, the dental clinic fraudulently billed Medicaid approximately $6.9 million. 

The investigation was conducted by Sergeant Alfred Paige, Investigative Auditor Daryl Middleton, and Captain Alexander Chancia of the Texas Attorney General’s Medicaid Fraud Control Unit (“MFCU”), in cooperation with the FBI and the Department of Health and Human Services – Office of Inspector General. MFCU’s Assistant Attorney General Kathryn Olson, who also serves as a Special Assistant U.S. Attorney with the U.S. Attorney’s Office for the Southern District of Texas, is prosecuting the case along with Assistant U.S. Attorney Grace Murphy. 

The OAG’s Medicaid Fraud Control Unit is dedicated to ensuring that those who exploit our healthcare system for personal gain are brought to justice by aggressively pursuing those who engage in healthcare fraud, working to safeguard taxpayer funds, and defending the integrity of vital healthcare programs. In the last fiscal year alone, the MFCU recovered more than $236 million in settlements and judgments for Texas taxpayers. In Texas, Medicaid costs taxpayers over $40 billion. Federal and industry authorities estimate that fraud comprises up to ten percent of the costs of the Medicaid program, making Medicaid fraud a $4 billion problem in Texas. 

The MFCU receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $20,944,200 for fiscal year (FY) 2023. The remaining 25 percent, totaling $6,981,395, is funded by the State of Texas. For every dollar of state funding, the OAG’s MFCU recovers more than 33 dollars for taxpayers. If you suspect Medicaid fraud or abuse, or patient neglect, please report it by visiting the OAG’s website.  

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[MM Curator Summary]: Yet another bogus MH claims fraud for $100k+. Yawn.

 
 

 
 

Clipped from: https://www.8newsnow.com/news/local-news/nevada-medicaid-fraud-case-ends-in-probation-110000-in-restitution-ordered/

 
 

LAS VEGAS (KLAS) — A Las Vegas behavioral health company was ordered to pay $110,000 in restitution in a Medicaid fraud case, according to the Nevada Attorney General’s Office.

Joy Behavioral Health and its owner, Edward Gamboa, were placed on two years probation after an investigation found the company billed Medicaid for services that were not provided to Medicaid recipients. The company was sentenced on a gross misdemeanor for intentional failure to maintain adequate records.

“The investigation revealed that Gamboa, through Joy, submitted fraudulent claims to Medicaid asserting that Rehabilitative Mental Health (RMH) services were provided to recipients when in fact they were not,” according to a Friday news release.

As part of a plea deal, Gamboa was previously sentenced to probation on a charge of acting without lawful authority. Gamboa is the sole owner of Joy Behavioral Health, which has an office at 3130 S. Rainbow Blvd.

District Court Judge Eric Johnson issued the sentence.

“Our office will continue to take action against those who abuse the privilege of receiving taxpayer funds that are supposed to help Medicaid recipients,” Nevada Attorney General Aaron D. Ford said. “My office will always endeavor to bring to justice health care providers engaged in such fraudulent billing practices.”

The Nevada Medicaid Fraud Control Unit (MFCU) receives 75% of its funding from the U.S. Department of Health and Human Services under a grant award. The remaining 25% is funded by the State of Nevada MFCU. Persons convicted of Medicaid fraud may also be administratively excluded from future Medicaid and Medicare participation.

Anyone wishing to report suspicions regarding any of these concerns may contact the MFCU at 702-486-3420 or 775-684-1100.

MM Curator summary

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[MM Curator Summary]: A giant humanitarian crisis has been created by fraudsters in AZ.

 
 

 
 

Clipped from: https://abcnews.go.com/Health/wireStory/navajo-nation-declares-widespread-medicaid-scam-arizona-public-100293149

A widespread Arizona Medicaid scam that has left an unknown number of Native Americans homeless on the streets of metro Phoenix is being declared a public health state of emergency by the Navajo Nation as fraudulent sober living homes lose their fundin…

 
 

A billboard is seen in Scottsdale, Ariz., Saturday, June 10, 2023, near the health care facility of the Salt River Pima-Maricopa Indian Community, which has been affected by a gigantic Medicaid fraud scheme involving sober living homes that promised hel…

The Associated Press

PHOENIX — A widespread Arizona Medicaid scam that has left an unknown number of Native Americans homeless on the streets of metro Phoenix is being declared a public health state of emergency by the Navajo Nation as fraudulent sober living homes lose their funding and turn former residents out onto the streets.

The emergency declaration was issued late last week by the Navajo Nation Commission on Emergency Management and signed this week by Navajo Nation President Buu Nygren, according to documents posted on the Facebook page of the tribe’s Operation Rainbow Bridge, which was created to deal with the scam’s effects on its enrolled members.

“There are significant concerns about the impacts to Navajo Nation lives from abrupt displacement that have affected an estimated 5,000 to 8,000 Navajo individuals, particularly in the exacerbation of medical, and public health risks associated with lack of immediate intervention and preventive services,” the declaration reads.

The declaration allows the tribe to add more personnel, travel resources, medical supplies, funding and other means of support to address the ongoing problem.

Navajo Nation Attorney General Ethel Branch said earlier this month that the tribe’s law enforcement teams over the course of several weeks made contact with more than 270 Native Americans released onto the streets of metro Phoenix by sober living homes that have been targeted by a state crackdown on fraudulent billing.

Navajos account for most Native Americans grappling with addictions who have been affected by the scam and subsequent crackdown.

The Salt River Pima-Maricopa Indian Community has also warned its members about the deceptive providers with billboards outside its reservation in Scottsdale, Arizona.

The Arizona Health Care Cost Containment system, the agency that manages Medicaid payments for the state, this week announced several more changes that aim to stop payments to deceptive organizations that have been billing for services that are not provided, not appropriate, or unnecessary.

The agency’s website says a six-month moratorium is being placed on new enrollments for certain types of residential and outpatient behavioral health providers and non-emergency transportation services. Some providers will now be required to have background checks and site visits.

Providers also can no longer bill the state for Medicaid money on behalf of others, and certain kinds of claims are now being flagged.

Payments have been cut off to more than 100 of providers suspected of fraudulent billing.

Arizona officials announced in May they were investigating a huge Medicaid funding scam that potentially affected thousands of people, most of them believed to be Native Americans.

State officials believe the fake homes have defrauded Arizona out of hundreds of millions of its share of federal Medicaid dollars. Arizona authorities so far have seized $75 million and have issued 45 indictments in the investigation that also includes the FBI and the U.S. Attorney General’s Office.

MM Curator summary

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[MM Curator Summary]: Mr. Banks stole 1M with bogus counseling claims. We have seen this movie before.

 
 

 
 

Clipped from: https://www.justice.gov/usao-ct/pr/brookfield-counselor-sentenced-30-months-federal-prison-defrauding-medicaid-more-1

Vanessa Roberts Avery, United States Attorney for the District of Connecticut, announced that GREGORY C. BANKS, 50, of Brookfield, was sentenced today by U.S. District Judge Michael P. Shea in Hartford to 30 months of imprisonment, followed by three years of supervised release, for health care fraud.

According to court documents and statements made in court, Banks owned and operated North East Counseling & Trauma Services and Gregory Banks Counseling, LLC.  North East Counseling & Trauma Services, which had an office in Danbury, provided counseling services to individual patients, including those with mental health and trauma issues.  Banks was enrolled individually as a Behavioral Health Clinician provider in the Connecticut Medicaid Program (“Medicaid”), but North East Counseling & Trauma Services and Gregory Banks Counseling LLC were never enrolled as providers in Medicaid.

Between January 2018 and July 2022, Banks submitted and caused to be submitted fraudulent claims to Medicaid for counseling services that were purportedly provided to Medicaid clients.  Specifically, Banks submitted claims for dates of service when no services of any kind had been provided to the Medicaid clients identified in the claims. 

In October 2020, the Connecticut Department of Social Services (DSS) audited Banks and his businesses and requested documentation from Banks for six sample clients.  In response, Banks made multiple false statements for the purpose of delaying the progress of DSS’s audit and to conceal his offense.  For example, in February 2021, Banks sent an email to DSS in which he falsely represented that one of the files DSS requested was destroyed by a water leak above his office when, in fact, no such water leak had occurred.

Through this scheme, Banks defrauded Medicaid of $1,044,387.08.  Judge Shea ordered Banks to pay full restitution.

Banks, who is released on a $100,000 bond, is required to report to prison on September 8.

This investigation was conducted by the U.S. Department of Health and Human Services, Office of the Inspector General (HHS-OIG) and the Federal Bureau of Investigation.  U.S. Attorney Avery acknowledged the valuable cooperation of the Connecticut Department of Social Services in the investigation.

This case was prosecuted by Assistant U.S. Attorney David T. Huang.

People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS.

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[MM Curator Summary]: Ms Batrus stole $40k and lots of members did not get the med management oversight needed for quality care.

 
 

 
 

Clipped from: https://www.wtaj.com/news/local-news/former-physicians-assistant-from-altoona-charged-with-40k-medicaid-fraud/

HUNTINGDON COUNTY, Pa. (WTAJ) — An Altoona woman is facing charges for racking up more than $40,000 in Medicaid payments when she was employed as a physician’s assistant, the Office of the Attorney General (OAG) reported.

Jennifer Batrus, 50, of Altoona, is accused of using the guise of the pandemic to submit payments from Medicaid for patients she never saw in person nor talked to on the phone during the COVID-19 pandemic.

According to the OAG, Batrus was employed as a physician’s assistant with American Family Psychiatry since March 2016. Through the investigation, it was learned that she would often travel between the Huntingdon and State College offices and see roughly 30 patients a day, four days a week.

The OAG said they were alerted by a Medicaid management company that there may be fraud taking place.

Partial building collapse in Blair County may be the end of a 1930s theater

Investigators spoke to employees and patients, as well as executed search warrants at both offices before speaking with Batrus, the criminal complaint reads.

It was discovered that Batrus stopped going to the office when the COVID pandemic struck. The company began to do appointments by phone, stressing it was important to at least speak with the patients on the phone before sending their medicine every month, the documents filed in court show.

Investigators found that many patients were getting prescriptions filled though never getting a phone call from Batrus, who still allegedly billed Medicaid for office visits.

When interviewed, Batrus allegedly claimed she did it for the money after her husband’s restaurant was closed due to COVID, investigators noted.

Forensic analysis showed that Batrus’ non-existent office visits between March and December 2020, 517 of them, totaled over $40,000 that was paid out by Medicaid.

Batrus is now facing multiple felony charges for fraud, theft and submitting claims with false info and no services rendered.

Stay up to date with news that matters to you with the WTAJ app on iPhone and Android by clicking here.

The Office of the Attorney General noted that Batrus’ license to practice medicine expired in Dec. 2022.

A preliminary hearing is scheduled for July 5.

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[MM Curator Summary]: Uri and Efraim are on the NY AG naughty list for $38M in no-nos. Related- the state has been watching these dudes since 2017. But lets not ask why its taken 6 years to get the case to this point.

 
 

Clipped from: https://www.mcknights.com/news/ny-brings-fresh-allegations-of-a-for-profit-nursing-home-pocketing-medicaid-funds/

 
 

 
 

New York’s attorney general wants a state court to force the owners of a Syracuse nursing home to answer questions about “pocketing” $37.6 million in government funding, while the accused’s attorneys say such related-party transactions and other suspect business transactions are common and acceptable. 

Uri Koenig and Efraim Steif, owners of Van Duyn Center for Rehabilitation and Nursing, face numerous allegations of diverting Medicaid funds for their own financial gain, inadequate staffing, and neglect. NY Attorney General Letitia James’ office also alleges that the owners are intentionally “keeping staffing levels low,” according to a June 7 court filing asking the New York Supreme Court order to compel the owners to talk.

The case is the latest in the AG’s quest to spotlight what she considers predatory and illegal financial practices that have in some cases led to reduced staffing and serious patient care concerns. This is at least the fourth case James has pursued against for-profit owners since November of 2022.

In November, James sued the owners and operators of Comprehensive at Orleans LLC, doing business as The Villages of Orleans Health and Rehabilitation Center, a 120-bed nursing home in upstate New York, alleging the illegally diverted $18.6 million in Medicare and Medicaid funds. In December, she filed similar cases against Cold Spring Hills Center for Nursing and Rehabilitation and Fulton Commons Care Center, both located on Long Island.

The most recent Medicaid case demonstrates the lengths some states are going to to rein in regularly used business practices amid an equally aggressive pursuit by federal regulators to bring transparency to the nursing home sector.

“The Attorney General should be permitted to question Respondents about these financial arrangements, which served to siphon government funds from their intended purpose of supporting required resident care,” says a filing the AG’s office shared with McKnight’s Long-Term Care News on Friday.

“The policies that keep staffing levels low and resident census high appear to stem from decisions made by those who control Van Duyn’s operations and business decisions, including Respondent owners,” the filing added. “This is further supported by financial documents demonstrating that Respondent owners diverted money away from resident care and into their pockets by way of disbursements and related company transactions.”

The filing notes that the 513-bed facility has 78 citations from the state Department of Health, including two pertaining to Actual Harm or Immediate Jeopardy. The facility has been a candidate for placement on the Special Focus Facility list, which denotes the poorest performers in the country, since 2018, officials added. The Attorney General’s Medicaid Fraud Control Unit initially opened an investigation into Van Duyne in late 2017, the filing said. 

“[The] investigation has also shown that, during the period of Van Duyn’s poor performance, significant fund transfers out of the nursing home, whereby Respondents funneled millions of dollars paid to Van Duyn by government programs for resident care to themselves and related party companies,” the court document said. “Indeed, a non-profit organization’s analysis found that Van Duyn’s owners routinely engage in related company transactions designed to siphon taxpayer funds away from resident care.”

According to the court document, Koenig and Steif either “own or are strongly affiliated” with related parties that conduct business with the nursing home, including Upstate Services Group, LLC, which provides administrative consulting services to Van Duyn; Fiscal Care, LLC, which provides Van Duyn’s billing services; CFare Foods, LLC, which provides Van Duyn’s food services. Koenig and Steif also control all or part of the company to which the facility pays a “vastly inflated rent,” the document said. 

David R. Ross, an attorney with O’Connell and Aronowitz, however, said the owners intend to provide a response to the Attorney General’s office showing that the way Van Duyn conducts business is in accordance with state regulations. 

“Related party transactions are the norm, as they create economies of scale and resulting cost savings which benefit everyone,” Ross said in a statement to McKnight’s. “These related party transactions are standard practices that are commonplace in New York State and throughout the country, and are characteristic of for-profit and nonprofit nursing homes, as well as hospitals. All related party transactions are fully transparent and are required to be, and have been, reported to the New York State Department of Health in annual cost reports.”

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[MM Curator Summary]: Alfonzo and 20 of his employees used a bogus counseling company to steal $3.4M of your tax dollars. Medicaid members also took kickbacks to help make it all work. They did not say thank you.

 
 

 
 

Clipped from: https://fox8.com/news/3-4m-judgment-in-cleveland-medicaid-fraud-case/

[In the player above, get a breakdown of the top stories on FOX8.com for Tuesday, June 13, 2023.]

CLEVELAND (WJW) — The owner of a Cleveland nonprofit offering mental health counseling, which for years defrauded Medicaid by filing fake claims, will spend three years in prison and must repay $3.4 million, a federal judge ruled Tuesday.

Alfonzo Bailey, 40, of Euclid, who founded Eye for Change Youth and Family Services in 2016, pleaded guilty Tuesday to conspiracy to commit healthcare fraud, according to a news release from U.S. Attorney Rebecca Lutzko of Ohio’s Northern District Court.

Suspect flees after armed robbery at University Hospitals

He was sentenced to 36 months in prison and ordered to pay $3,465,643 in restitution for the scheme, in which the nonprofit’s employees conspired to bill the Ohio Department of Medicaid for services that were never rendered according to the U.S. attorney’s office.

The nonprofit Eye for Change offered mental health counseling, case management, job training and supportive housing, among other services, according to the release.

A superseding indictment handed up in May 2021
charged Bailey, the nonprofit and 20 employees with healthcare fraud, money laundering and other related charges in the scheme, which lasted from February 2017 to September 2020.

Prosecutors alleged employees were directed to misdiagnose Medicaid beneficiaries, seeking authorization from the state Medicaid department to offer services at increased rates. Some employees submitted false notes to show proof of the services, according to prosecutors.

Others were accused of paying kickbacks including cash, gift cards and rent or bill payments to those Medicaid beneficiaries, in order to add them to the nonprofit’s clientele, then sending more fraudulent bills to Medicaid.

“These individuals engaged in a scheme to defraud taxpayers by submitting fraudulent billing to a federally funded healthcare program, which is supported by hard-working citizens,” FBI Special Agent in Charge Eric Smith is quoted in a news release from November 2020, when Bailey and eight others were initially indicted.

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At the time, Eye for Change was associated with properties in Cleveland, Cleveland Heights and Columbus, according to the 2020 news release.

“There are actually real people out there who are suffering and need help,” Attorney General Dave Yost said at the time.  “You don’t have to make up imaginary patients. A jury of their peers will undoubtedly know some of them. I’m grateful for the state-federal partnership that is bringing these fakes to justice.”

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[MM Curator Summary]: Hari did lots of unnecessary cardiac procedures to steal $5M of your tax dollars. He did not say thank you.

 
 

 
 

Clipped from: https://www.justice.gov/usao-ednc/pr/fayetteville-cardiologist-agrees-pay-over-5-million-resolve-allegedly-false-medicare

RALEIGH, N.C. – Fayetteville, North Carolina cardiologist Dr. Hari Saini and his current practice, Carolina Heart and Leg Center, P.A., agreed to pay $5,015,554 to the United States and North Carolina to resolve allegedly false Medicare and Medicaid claims. 

“This civil fraud settlement demonstrates our steadfast commitment to protect taxpayer money and guard the integrity of our vital health care programs,” said U.S. Attorney Michael Easley.  “Medical doctors should never bill for unnecessary procedures.  Those who do will be held accountable.  Our office will zealously pursue damages and civil penalties against medical professionals where warranted.”

This settlement arose from whistleblower allegations that Dr. Saini and his cardiology practice performed unnecessary atherectomy procedures to remove minor plaque blockage in leg arteries in patients.  The United States filed a complaint against Dr. Saini, Carolina Heart and Leg Center, and Carolina Cape Fear Medical Group, alleging that Defendants “systematically overstated the stenosis percentage” to justify medically unnecessary atherectomies for the maximum number of procedures for their patients. More specifically, the Government alleged that Dr. Saini—who was one of the highest billing cardiologists in North Carolina for this type of claim—conducted “risky and invasive atherectomy procedures to unnecessarily remove plaque blockage that was, at best, only minimally present, all in blatant disregard for patient safety and Program billing requirements.”  Based upon billing and medical records, Defendants were paid millions from Medicare and Medicaid, which the Government alleged was not supported by the retained medical records for the services provided and billed. 

Ultimately, after six years of discovery and litigation, and with trial looming, Dr. Saini and his practice agreed to pay more than $5 million to resolve the False Claims Act allegations. 

“Physicians cannot perform procedures on patients who don’t need them just to make more money,” said Attorney General Josh Stein. “That’s a waste of taxpayer resources and a fundamental abuse of the trust we put in doctors. My office will hold accountable health care providers when they commit fraud for their own enrichment.”

The federal and state False Claims Acts mandate that the Governments recover triple the money falsely obtained, plus substantial penalties for each false claim submitted, and attorneys’ fees and costs to the whistleblower.  It should be noted that the civil claims resolved by settlement here are allegations only, and that there has been no judicial determination or admission of liability.  Dr. Saini and his practice deny these fraud allegations.

This matter was handled in partnership between the United States Attorney’s Office of the Eastern District of North Carolina and the Medicaid Investigations Division of the North Carolina Attorney General’s Office.  Assistant United States Attorney Neal Fowler and North Carolina Senior Deputy Attorney General Eddie Kirby represented the United States and State of North Carolina in this civil action.  The investigation was conducted by the HHS Office of Inspector General, including Special Agent Craig Schiffbauer, and the North Carolina Medicaid Investigations Division.

MM Curator summary

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[MM Curator Summary]: “Atlanta man” did something. In 2018, and in 2020.

 
 

Clipped from: https://www.11alive.com/article/news/local/atlanta-man-medicaid-fraud-indictment-2018-claims/85-2f605799-d190-41e8-afd3-90ccf8b5da90

 
 

 
 

ATLANTA — An Atlanta healthcare provider has been indicted on 26 counts of Medicaid fraud and three counts of felony forgery after he allegedly submitted fraudulent claims, according Georgia Attorney General Chris Carr’s office. 

The 55-year-old man was indicted last Monday after the Attorney General’s Office Medicaid Fraud Division presented evidence to a Fulton County Grand Jury.

“We are working each day to protect taxpayer dollars by putting a stop to Medicaid fraud in our state,” Attorney General Carr said.

He allegedly submitted the claims for fake services he didn’t provide under his company to get a reimbursement payment from the government program in 2018. 

He was a licensed healthcare provider in Georgia, according a court document.

Court documents also show that the 55-year-old also forged a few documents in 2020, the indictment stated. 

“Ensuring the integrity of providers and services is a key part of our efforts. Georgia’s Medicaid program is meant to care for our most vulnerable, and we will not tolerate those who would abuse this public trust,” Carr added.

The indictment comes after Georgia received it’s own Medicaid fraud division which receives majority of its funding from the U.S. Department of Health.

If convicted, the man could pay up to a fine of three times what the government program lost and $11,000 for each fraudulent claim, according to the U.S. Department of Health and Human Services.

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