Medicare Fraud Cases on the Rise

Medicare Fraud Cases on The Rise

Federal prosecutors brought a record number of cases of health care fraud in fiscal 2011, a new report said, with Florida and its huge Medicare-dependent population remaining the epicenter of fraudulent claims.

The latest data, drawn from federal records by the Transactional Records Access Records database at Syracuse University, showed total prosecutions jumped 68.9 percent to 1,235 cases compared to 2010, a record increase.

The huge increase was fueled largely by a sharp jump in cases brought in Puerto Rico, where prosecutors charged 548 defendants with health care fraud last year, up from just 119 the previous year. Most of those were minor cases. But even without the Puerto Rican cases, fraud prosecutions nationwide were up sharply and reached the highest level since 2000.

Medicare Fraud Cases

Miami led the nation in activity, accounting for nearly one out of every nine health care fraud prosecutions, followed by Houston. Together, federal prosecutors in those two districts accounted for over one out of every five health care fraud prosecutions.

“The good news is
there’s lots of prosecutions.
The bad news is there’s
lots of prosecutions.”
The Obama administration stepped up its enforcement activity in late 2009 with the creation of tasks forces in nine cities to root out Medicare and Medicaid fraud. “They’re really going after these cases very aggressively, and I think you’ll see prosecutions increase even more over the next few years,” said Louis Saccoccio, chief executive officer of the National Health Care Anti-Fraud Association, which was launched in 1985 by insurers to help root out both private and public sector fraud in the industry.

“The good news is there’s lots of prosecutions,” he said. “The bad news is there’s lots of prosecutions. The real question is what will CMS (the Center for Medicare and Medicare Services) do to prevent these frauds from taking place in the first place.”

A typical case concluded in Trenton last week when a federal judge sentenced a former senior manager of Columbia, Md.-based Maxim Health Care Services, one of the nation’s leading home health care providers, to five months in prison for setting up a phony office that billed Medicaid and the Veterans Administration nearly a million dollars. The criminal charges were part of a nationwide investigation of Maxim that led in September to an out-of-court settlement where the firm – to avoid a conviction that might have disqualified it from the programs – agreed to pay the government $150 million in criminal and civil penalties.

Experts and even defense attorneys say health care fraud, estimated to cost the government $70 billion a year, won’t be curbed until the government figures out how to short-circuit schemes through better monitoring of claims before they are paid and better screening of firms before they are allowed to sell services to the programs. Last June, CMS launched a data-mining program that will review Medicare claims before payment to identify individual providers that show huge spikes in activity. “CMS is on the right track,” Saccoccio said.

“They have to blow up the bill now, investigate later system,” agreed Andrew Ittleman, a white collar criminal defense attorney at Fuerst Ittleman in Miami. While he says that many cases involve companies in legitimate billing disputes with the government, he agreed “it’s not at all misguided given the size of the problem and the magnitude of the fraud.”

“The more sinister cases down here involve people who set up broom closets without an address and bill Medicare as long as they can before they high-tail it to Cuba or wherever in Latin America,” he said. “Magistrates aren’t even giving pre-trial release to some of these defendants because we don’t have an extradition treaty with Cuba.”

This story appeared first in The Fiscal Times.

Senators want better assessment of Medicare fraud detection program

BY JOSEPH MARKS 12/20/2011

Medicare officials should better evaluate whether a new system designed to spot fraudulent claims and roll back the program’s roughly $50 billion in annual improper payments is living up to its potential, a bipartisan group of senators said Tuesday.

The Centers for Medicare and Medicaid Service responded that it had been measuring results from the $100 million system since soon after its July launch and would update Congress on the results soon.

“The predictive modeling program is well on its way to achieving the kind of results CMS expected,” agency officials said.

CMS plans to launch the new system nationwide this summer. But without clear metrics to gauge successes and failures neither the agency nor Congress will be able to determine whether the program is doing what it’s supposed to, the senators said in a letter to Peter Budetti, director of CMS’ Center for Program Integrity.

“As is often said, one cannot manage what one cannot measure,” Sens. Tom Carper, D-Del.; Scott Brown, R-Mass.; and Tom Coburn, R-Okla.; said. Carper is chairman of the Senate Homeland Security Subcommittee on Federal Financial Management, which oversees CMS’ financial issues. Brown is that panel’s ranking Republican and Coburn, a physician, is a subcommittee member.

The predictive analysis tool was designed to flag common patterns of Medicare fraud such as suspicious billing patterns or a great distance between the hospital where treatment occurred and the claimant’s home address. The plan is for CMS officials to halt those payments and immediately investigate them for possible fraud.

Legislative requirements that most Medicare claims be paid within 30 days traditionally has meant that CMS paid out claims before investigating them — what officials call the “pay and chase” model.

The senators’ letter concludes with a list of 10 questions focused on how much money the tool has clawed back, what lessons CMS officials have learned from the system’s implementation so far, and whether those lessons have changed how the agency pays claims and which Medicare services providers it contracts with.

The predictive analytics program is similar to several fraud detection tools used by the Recovery Accountability and Transparency Board, which tracks spending on President Obama’s $840 billion stimulus bill. That program has kept stimulus money lost to fraud at below 1 percent compared with a rate of up to 7 percent for government spending generally.

Plans to roll out similar tools on a governmentwide basis are working their way through Congress and the White House.

Miami Medicare Fraud: Medicare fraud bill reintroduced

From the Miami Herald Blog:

Medicare fraud bill reintroduced U.S. Rep. Ileana Ros-Lehtinen, R-Miami, has reintroduced legislation that would double the fines and jail time for people convicted of Medicare fraud. It also creates a new criminal offense punishable with a 10 year minimum sentence for those who knowingly sell or distribute the ID numbers of Medicare beneficiaries. The legislation also bars those who have been part of Medicare fraud in the past from billing Medicare if they switch companies. It also facilitates real-time information sharing among law enforcement agencies to aid in uncovering and dismantling Medicare scams. “South Florida has been known as the epicenter of Medicare fraud for years,” she said. “It is time we took the fight to those who seek to defraud Medicare and prey on our most vulnerable citizens. This bill not only increases the penalties for those who engage in Medicare fraud, but also sets up a pro-active paradigm that will help stem the tide of abuse in South Florida and across the nation.” The bill takes particular aim at Medicare theft in Miami-Dade County, widely regarded as the nation’s capital of healthcare fraud. Medicare fraud in South Florida costs taxpayers between $3 billion and $4 billion every year, according to law enforcement and healthcare officials. Nationwide, Medicare and other healthcare fraud is estimated to cost $68 billion annually.

Former Maxim Healthcare Services Senior Manager Sentenced To Prison For Health Care Fraud

FOR IMMEDIATE RELEASE

Eight Others, Including Senior Managers, Previously Sentenced for
Felony Charges Arising out of Maxim’s Activities

TRENTON, N.J. – A former senior manager and 13-year employee of Maxim Healthcare Services, Inc. (“Maxim”), was sentenced today to five months in prison and five months of home confinement with electronic monitoring for his involvement in the unlicensed operation of Maxim office that billed nearly a million dollars to government health care programs, J. Gilmore Childers, First Assistant U.S. Attorney announced.

Bryan Lee Shipman, 38, of Athens, Ga., pleaded guilty in Trenton federal court on June 17, 2010, to an Information charging him with one count of health care fraud. Shipman was charged in connection with his role as a regional account manager supervising Maxim’s decision to open and operate Maxim’s Gainesville, Ga., office without a license from 2008 through 2009, when he and others directed billings from that office to be submitted for reimbursement by the Medicaid program as if they were from another, licensed office. Shipman entered his guilty plea before U.S. District Judge Anne E. Thompson, who also imposed the sentence today in Trenton federal court.

On Sept. 12, 2011, Maxim – one of the nation’s leading providers of home healthcare services – entered into a settlement agreement to resolve criminal and civil charges relating to a nationwide scheme to defraud Medicaid programs and the Veterans Affairs program of more than $61 million. Maxim was charged in a criminal Complaint with conspiracy to commit health care fraud, and entered into a Deferred Prosecution Agreement (“DPA”) with the Department of Justice. The agreement allows Maxim to avoid a health care fraud conviction on the charges if it complies with the DPA’s requirements. As required by the DPA, Maxim agreed to pay approximately $150 million – a criminal penalty of $20 million and approximately $130 million in civil settlements in the matter, including to settle federal False Claims Act claims.

Shipman is one of nine individuals – eight former Maxim employees, including three senior managers, and the parent of a former Maxim patient – to have pleaded guilty to and been sentenced on felony charges arising out of the submission of fraudulent billings to government health care programs, the creation of fraudulent documentation associated with government program billings, or false statements to government health care program officials regarding Maxim’s activities.

According to documents filed in this and related cases and statements made in court:

Shipman had been employed by Maxim for 13 years, the last eight as a regional account manager. As a regional account manager, Shipman reported directly to one of two nationwide vice presidents, who in turn reported to Maxim’s president. He also managed 13 offices in 2008 with hundreds of employees and total annual sales of more than $42 million, much of which derived from government programs. In his last full year of employment, Shipman earned more than $325,000, and was among the top 25 individuals at Maxim in terms of compensation out of the more than 80,000 individuals employed by Maxim in that year.

Shipman’s annual compensation – which ranked him within the top .03% of the Company – was based to a significant degree on meeting sales goals. Shipman said his superiors demanded levels of growth based “not on any market analysis, but simply on a belief that dramatic growth was necessary regardless of market conditions.” It was in response to that pressure, Shipman said, that he authorized and supervised the unlicensed operation of the Gainesville office.

At one point, when Maxim employees believed a state regulator would be visiting the office, lower-level employees were directed by Shipman and others to provide false information to the state regulator in an effort to prevent the Medicaid program from learning about the unlicensed operation of the office.

In addition to the prison term, Judge Thompson sentenced Shipman to two years of supervised release and ordered him to pay a $10,000 fine.

The other eight individuals who pleaded guilty were sentenced by Judge Thompson as follows:

Gregory Munzel, 35, of Charleston, S.C., was employed as a regional account manager, reporting directly to a vice president, responsible for Maxim offices throughout the southeastern United States. He pleaded guilty on Dec. 4, 2009, to one count of making false statements relating to health care fraud matters. During his plea hearing, Munzel admitted that he was aware individuals he supervised were submitting time cards for work that had not actually been done – a practice Munzel said was in response to pressure from Maxim superiors to increase revenue. Munzel also acknowledged forging caregiver credentials such as CPR cards throughout his time at Maxim, in order to make it appear that the caregivers were properly credentialed, when they were not. Munzel indicated he learned the practice from his supervisors when he first joined Maxim, and that those under him engaged in the practice when he took on a leadership role with the company. Munzel was sentenced on Sept. 29, 2011, to three months of home confinement as part of a two-year term of probation. Munzel was also ordered to pay a $1,000 fine.

Matthew Skaggs, 39, was employed as a regional account manager, reporting directly to a vice president, responsible for Maxim’s offices in Texas. He pleaded guilty on Sept. 23, 2010, to making false statements relating to health care fraud matters. During his plea hearing, Skaggs acknowledged having knowingly made false statements to a surveyor from Texas’ Medicaid Program, who was investigating the operation of an unlicensed Maxim office in Houston. Skaggs was sentenced on June 10, 2011, to a three-year term of probation and ordered to pay a $4,000 fine.

Andrew Sabbaghzadeh, 30, of Clay, N.Y., was employed as an account manager; and Jason Bouche, 27, of Paradise Valley, Ariz., was employed as a recruiter at Maxim’s Tempe, Ariz. office. They pleaded guilty to health care fraud on Nov. 4, 2009, and April 23, 2010, respectively. During their plea hearings, Sabbaghzadeh and Bouche acknowledged creating fraudulent time cards in order to bill government programs. They acknowledged that in some instances, Maxim employees cut signatures from legitimate time cards and pasted them onto forged time cards in order to submit them for reimbursement. Sabbaghzadeh was sentenced on Sept. 26, 2011, to six months of home confinement as part of a three-year term of probation. Sabbaghzadeh was also ordered to pay a $2,000 fine. Bouche was sentenced on Nov. 17, 2011, to a two-year term of probation and ordered to pay a $500 fine.

Donna Ocansey, 49, of Medford, N.J., was employed as a director of clinical services (supervising nurse) in Maxim’s Cherry Hill, N.J., office. She pleaded guilty on May 28, 2010, to making false statements relating to health care fraud matters. Ocansey, a registered nurse (RN), had responsibility for, among other things, ensuring that Medicaid-required supervisory visits of patients were conducted periodically – meaning that an RN periodically visited each patient to check each patient’s condition and the care the patient was receiving from Maxim Home Health Aides, who lack the skills and training of RNs. During her plea hearing, Ocansey acknowledged that she fabricated documentation in order to make it appear that other nurses had conducted Medicaid-mandated supervisory visits, when in fact they had not. Ocansey stated that she fabricated documentation in response to pressure from her superiors at Maxim, who expected her to make sure that all supervisory visits were completed without providing adequate resources for her to do so. Ocansey was sentenced on Oct. 18, 2011, to four months of home confinement as part of a a three-year term of probation. Ocansey was also ordered to pay a $2,000 fine.

Mary Shelly Janvier-Pierre, 43, of Lake Worth, Fla., and Sandy Cave, 39, of West Palm Beach, Fla., pleaded guilty to health care fraud on Feb. 1, 2010, and June 21, 2010, respectively. During their plea hearings, Janvier-Pierre, who had been employed by Maxim’s West Palm Beach office as a licensed practical nurse; and Cave, the mother of a former pediatric patient of Maxim, admitted to their roles in a scheme to fraudulently bill Medicaid, through Maxim, for services that were not rendered. Janvier-Pierre and Cave acknowledged that they agreed to submit billings as if Janvier-Pierre was taking care of Cave’s child, when she was not. Janvier-Pierre and Cave then split the money Janvier-Pierre received for purportedly providing the care. As a result of the scheme, Maxim was paid more than $70,000 by Florida’s Medicaid program. Janvier-Pierre was sentenced on Sept. 21, 2011, to six months of home confinement as part of a three-year term of probation. Cave was sentenced on Nov. 17, 2011, to five months of home confinement as part of a three-year term of probation. Cave was also ordered to pay a $1,000 fine.

Marion Morton, 45, of North Charleston, S.C., was employed as a home health aide and personal care assistant by Maxim’s Charleston, S.C., office. He pleaded guilty on May 3, 2010, to one count of making false statements relating to health care fraud matters. During his plea hearing, Morton acknowledged that, at the instruction of Maxim employees, he fabricated timecards reflecting work he had not done. On multiple occasions, Maxim submitted bills to Medicaid based on timecards which showed he worked more than 24 hours on certain days. Morton was sentenced on May 24, 2011, to a three-year term of probation and ordered to pay a $5,000 fine.

First Assistant U.S. Attorney Childers credited special agents and investigators from HHS/OIG, under the direction of Special Agent in Charge Thomas ODonnell; the FBI, under the direction of Special Agent in Charge Michael B. Ward; and VA OIG, under the direction of Special Agent in Charge Jeffrey Hughes for conducting the multi-year investigation.

The government is represented by Assistant U.S. Attorney Jacob T. Elberg of the U.S. Attorney’s Office Health Care and Government Fraud Unit.

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Defense counsel:

Maxim: Laura Laemmle-Weidenfeld Esq.; Robert Luskin Esq., Washington
Gregory Munzel: John Lacey Esq., Roseland, N.J.
Bryan Lee Shipman: Peter Bennett Esq., Middletown, N.J.
Matthew Skaggs: David Sellinger Esq., Florham Park, N.J.
Andrew Sabbaghzadeh: James Hopkins Esq., Syracuse, N.Y.
Jason Bouche: Chester Keller Esq., Assistant Federal Public Defender, Newark
Donna Ocansey: Jeffrey Carney Esq., Hackensack, N.J.
Mary Shelly Janvier Pierre: Michael Salnick Esq., West Palm Beach, Fla.
Sandy Cave: Chester Keller Esq., Assistant Federal Public Defender, Newark
Marion Morton: John Renner Esq., Marlton, N.J.

Former Owner And President Of Allied Health Care Services, Inc. Sentenced To More Than 16 Years In Prison In $135 Million Medical Equipment Lease Scheme

FOR IMMEDIATE RELEASE

Charles Schwartz Also Ordered to Pay $155 Million in Restitution and Forfeiture

NEWARK, N.J. – The former owner and president of Allied Health Care Services, Inc., an Orange, N.J., durable medical equipment corporation, was sentenced today to 195 months in prison for organizing and executing a $135 million phony lease scheme that caused losses of more than $80 million and victimized more than 50 financial institutions, U.S. Attorney Paul J. Fishman announced.

Charles K. Schwartz, 58, of Sparta, N.J., pleaded guilty on April 13, 2011, to one count of mail fraud. Schwartz was previously charged by Complaint and arrested by special agents of the FBI on September 2, 2010. He has been in federal custody since that time. Schwartz entered his guilty plea before U.S. District Judge Susan D. Wigenton, who also imposed the sentence today in Newark federal court.

“Charles Schwartz, who once bragged that victims fell for his fraud ‘hook, line and sinker,’ stole tens of millions of dollars from financial institutions and bankrupted his own company to float his Ponzi scheme and luxury lifestyle,” said U.S. Attorney Fishman. “It is particularly offensive that he claimed to be leasing medical equipment that is used by people with significant healthcare needs, and his deception justifies his 16-year sentence. The health care industry is a vital part of New Jersey’s fabric, and those who criminally exploit our success will not be tolerated.”

According to documents filed in this case and statements made in court:

From at least 2002 through July 2010, Schwartz, through Allied Health Care Services, Inc. (“Allied”), convinced financial institutions to pay more than $135 million by telling them that the money would be used to lease valuable medical equipment. In reality, the purported medical equipment supplier did not provide Schwartz and Allied with any equipment during that time. Instead, the “supplier” created phony invoices which appeared to reflect legitimate transactions.

As part of the scheme, Schwartz approached various financial institutions and informed them that Allied needed to lease particular medical equipment. Using the phony invoices from the “supplier,” Schwartz convinced the financial institutions to enter into leasing arrangements. Pursuant to these arrangements, the financial institutions purchased the medical equipment – which they immediately leased to Schwartz and Allied – and sent payment for the medical equipment to the purported supplier. The “supplier” then sent the money received from the financial institutions (minus his 3 to 5 percent payment) to an entity created by Schwartz to facilitate the fraud.

In addition to spending millions of dollars on properties in New Jersey and New York, including a horse farm, Schwartz used the money in Ponzi-scheme fashion to repay earlier bank loans that were a part of the scheme. By August 2010, several financial institutions from which Schwartz had obtained loans filed lawsuits against Schwartz and Allied, claiming he owed them at least $20 million. Allied and Schwartz were forced into involuntary bankruptcy in August 2010 and September 2010, respectively. Losses from the scheme now total at least $80 million. Schwartz admitted that more than 50 victim financial institutions lost a total of between $50 and $100 million as a result of the scheme.

Schwartz and the medical equipment “supplier” undertook efforts throughout the scheme to deceive bank examiners who wanted to inspect the non-existent medical equipment, which had been purchased by the financial institutions. Schwartz admitted that in advance of expected inspections by financial institutions, he directed others to alter serial numbers or create fraudulent serial numbers on existing ventilators to match fraudulent invoices he had supplied to the various financial institutions. At times, when financial institutions sought to review documentation regarding Allied’s leasing of the ventilators to its customers, Schwartz falsely told the financial institutions that the information was protected by Health Insurance Portability and Accountability Act regulations. At one point during an August 2010 conversation between Schwartz and the “supplier,” Schwartz commented that the financial institutions had fallen “hook, line and sinker” for the false explanation given to bank examiners who asked why the purported supplier used his home address on certain invoices.

In addition to the prison term, Judge Wigenton sentenced Schwartz to three years of supervised release and ordered him to pay $80 million in restitution. Judge Wigenton also ordered Schwartz to forfeit $75 million.

U.S. Attorney Fishman credited special agents of the FBI, under the direction of Special Agent in Charge Michael B. Ward, for the investigation which led to today’s sentence.

The government is represented by Assistant U.S. Attorneys Jacob T. Elberg and Joseph Mack of the U.S. Attorney’s Office Health Care and Government Fraud Unit in Newark.

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Defense counsel: John Whipple Esq., Chatham, N.J.

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