Saturday, June 8, 2013

IRS Examples of Healthcare Fraud Investigations - Fiscal Year 2013 -

Examples of Healthcare Fraud Investigations - Fiscal Year 2013

Examples of Healthcare Fraud Investigations - Fiscal Year 2013

The following examples of healthcare fraud investigations are written from public record documents on file in the court records in the judicial district in which the cases were prosecuted.
Former Nigerian Fugitive Sentenced for Health Care Fraud and Money Laundering
On May 10, 2013, in Houston, Texas, Godwin Chiedo Nzeocha, a naturalized United States citizen originally from the Federal Republic of Nigeria, was sentenced to 109 months in prison and ordered to pay more than $26 million in restitution to Medicare and Medicaid, jointly with his co-conspirators. In addition, Nzeocha agreed to forfeit $1,098,320 to the United States. Nzeocha pleaded guilty on October 19, 2012 to one count of conspiracy to commit health care fraud and one count of money laundering. According to court documents, Nzeocha left the United States in 2009 to avoid arrest after receiving a telephone call from a City Nursing co-conspirator the day Umawa Imo, owner of City Nursing Services of Texas Inc., was arrested. Nzeocha had an agreement with Imo to sign his name on City Nursing patient documents as the provider of physical therapy services that he knew he was not qualified to authorize. The documents included blank treatment data forms, progress notes and daily physical therapy records. Nzeocha further admitted to knowing Imo was buying Medicare beneficiary information from recruiters and paying Medicare beneficiaries cash in order to bill for physical therapy services that were not provided. Nzeocha received approximately $1,098,320 from City Nursing. Between December 3, 2007 and June 26, 2009, when Nzeocha worked at City Nursing, the company billed Medicare and Medicaid for approximately $35,819,508 worth of physical therapy services that were not provided and received approximately $26,233,122 as payment for those services from Medicare and Medicaid. Imo was sentenced in October 2011 to 327 months in prison.
Leader of Medicaid Fraud Conspiracy Sentenced for Fraud and Money Laundering
On May 6, 2013, in Statesville, N.C., Betty Ann Cook, of Sparta, N.C., was sentenced to 40 months in prison, two years of supervised release and ordered to pay $325,820 in restitution. On April 25, 2012, Cook pleaded guilty to one count of health care fraud conspiracy and one count of money laundering conspiracy. According to court documents, Cook was the owner of Families First Home Health Care, a home health care company located in Alleghany Co., N.C. Cook’s company was enrolled with Medicaid to provide personal care services to Medicaid recipients. These services are provided by a home health aide in the recipient’s home. From December 2006 to about October 2010, Cook participated in a scheme to defraud Medicaid by submitting false and fraudulent claims to Medicaid seeking reimbursement for patient care services that were either not provided, not authorized by a physician, or were not based upon a valid in-home eligibility assessment performed by a qualified registered nurse, as required by Medicaid policy.
Ohio Doctor Sentenced on Health Care Fraud and Tax Charges
On March 25, 2013, in Toledo, Ohio, Darrell A. Hall, a medical doctor, was sentenced to 60 months in prison. Hall pleaded guilty to conspiracy to distribute a controlled substance, health care fraud and a tax count. According to court documents, Hall was licensed to practice medicine and operated a practice under the name “EDM Health Services, LLC.” He was also a registered provider to Ohio Medicaid, which provides free health benefits to qualified low-income Ohio residents. Between August 2008 through May 2009, Hall conspired with others to distribute 1,300 pills of oxycodone for no legitimate medical purpose. In addition, between January 2007 and December 2009, he fraudulently billed Ohio Medicaid in the amount of $78,113. Hall also failed to pay $97,384 in taxes that he owed to the IRS on behalf of EDM Health Services, LLC, between 2007 and 2010.
Doctor Sentenced for Health Care Fraud and Tax Evasion
On March 1, 2013, in Wheeling, W.Va., Barton Joseph Adams, of Parkersburg, W.Va., was sentenced to 50 months in prison for health care fraud and tax evasion.  Adams was also ordered to forfeit $3,724,721 to the federal government and to pay $3,136,293 in restitution to various healthcare providers, including Medicare and Medicaid. According to court documents, Adams, a doctor of osteopathic medicine, owned and operated “Interventional Pain Management” in Vienna, W.Va. Adams previously admitted to making fraudulent claims for health care proceeds and to willfully attempting to evade taxes. Josephine Adams, the wife of Dr. Adams, was convicted of assisting her husband in the laundering of nearly $4 million dollars of health care fraud proceeds. The evidence presented showed that the fraud proceeds were first deposited into accounts in West Virginia and then were moved into accounts around the United States before being placed into accounts in Canada, China and the Philippines.
Texas Podiatrist Sentenced for Health Care and Tax Fraud
On January 31, 2013, in Sherman, Texas, Shannon Gallentine, of Maypearl, Texas, was sentenced to 24 months in prison and ordered to pay restitution in the following amounts: $407,942 to the IRS, $254,377 to Medicare, $110,622 to Medicaid, and $26,628 to Blue Cross Blue Shield. Gallentine pleaded guilty on May 10, 2012, to one count of health care fraud and one count of failing to file an income tax return. According to court documents, from January 2004 through May 2007, Gallentine, a podiatrist, owned and operated Ambulatory Foot Care in Lancaster, Texas. During this time, Gallentine submitted false and fraudulent claims to Medicare seeking reimbursement for procedures he did not perform. As a result of these false claims, Gallentine received in excess of $365,000 to which he was not entitled. Additionally, Gallentine willfully failed to file federal income tax returns for calendar years 2004 and 2005.
Florida Chiropractor Sentenced for Conspiracy to Commit Mail Fraud in Connection with Staged Accident Scheme
On January 31, 2013, in Miami, Fla., Jennifer Adams, of Boca Raton, was sentenced to 54 months in prison, three years of supervised release and ordered to pay $1,920,424 in restitution. Adams, a chiropractic doctor, pleaded guilty to a one-count Information charging her with conspiring with others to commit mail fraud for her role in a staged accident fraud scheme. According to court documents, to execute the fraud scheme, recruiters sought out drivers and their friends and family members to participate in staged accidents.  Accident participants were directed by the recruiters to chiropractic clinics that were controlled by co-defendants.  Adams agreed to place her name on the corporate paperwork for two clinics, thus utilizing her status as a licensed chiropractic physician, to allow the clinics to bill insurance companies directly for claims without obtaining additional licensure from the State of Florida. Adams initially believed the clinics to be operating legitimately. Sometime thereafter, Adams became aware that her license and status as a chiropractor was being used to fraudulently submit claims to insurance companies. Adams realized these patients did not require the medical treatment they sought. Adams continued to work at both clinics signing prescriptions for plans of treatment that she knew were not medically necessary and that she knew were being submitted for reimbursement to numerous insurance companies.  From the time that Adams was told about the fraud until the clinics were closed by law enforcement, the clinics submitted fraudulent claims that resulted in more than ten insurance companies making total payments of $1,920,424.
California Doctor Sentenced for Role in Medicare Scam
On December 17, 2012, in Los Angeles, Calif., Dr. Kenneth Thaler, of Westminster, was sentenced to 12 months in prison and ordered to pay approximately $11 million in restitution to the Medicare program. According to court documents, Thaler admitted homeless patients to the Tustin Hospital and Medical Center after they had been driven from “Skid Row” in downtown Los Angeles as part of a Medicare fraud scheme. Thaler admitted approximately 60 patients per month, including some who did not require hospitalization. The patients were recruited by marketers who were being paid kickbacks by recruiters such as Estill Mitts to refer homeless Medicare and Medi-Cal beneficiaries for in-patient hospital stays. After Thaler admitted these patients, he and the hospital billed Medicare and Medi-Cal for in-patient services, even if it was not medically necessary for the patient to be hospitalized. Mitts who operated a center that recruited homeless people to receive unnecessary health services pleaded guilty in September 2008 to conspiracy to commit health care fraud, money laundering and tax evasion. He is awaiting sentencing.
Defendant Sentenced in Multi-Million Dollar Health Care Fraud Case
On November 5, 2012, in Houston, Texas, Tony Nnonso Obi, a naturalized U.S. citizen from the Federal Republic of Nigeria, was sentenced to 41 months in prison for his role in a massive health care fraud that billed the Medicare and Medicaid programs for more than $45 million. Obi pleaded guilty in August 2012 to one count of conspiracy to commit health care fraud and one count of money laundering. As part of his plea, Obi admitted entering into an agreement with Umawa Imo, the owner of City Nursing, to receive 15 percent of the money City Nursing obtained from Medicare for services billed on individuals referred by Obi. Imo paid Obi $1,051,425. Imo is currently serving more than 27 years in prison for his role in the conspiracy.
Michigan Physical Therapist Sentenced on Health Care Fraud and Money Laundering Charges
On October 29, 2012, in Grand Rapids, Mich., Chyawan Bansil, a physical therapist from Farmington Hills, Michigan, was sentenced to 13 months prison, one year of supervised release, and ordered to pay almost $250,000 in back taxes. In addition, Bansil forfeited over $500,000 in assets which had been seized by the government and paid an additional $2.25 million dollars to resolve related civil claims under the False Claims Act. Bansil will also be excluded from participating with Medicare and Medicaid for a minimum of five years. According to court documents, between February 2007 and January 2012, Bansil defrauded Medicare, Medicaid, and Blue Cross Blue Shield of Michigan of more than $1 million by causing those programs to be billed for expensive nerve conduction studies and needle electromyography tests that Bansil did not perform. Bansil was also laundering the proceeds of his fraud scheme in order to avoid taxes.

Physician Pleads Guilty to Health Care Fraud Charges for "falsely recording severity of patients illnesses"

Defendant is the Third Cardiologist Nationwide to be Criminally Prosecuted for Health Care Fraud Related to the Placement of Heart Stents
U.S. Attorney’s Office June 05, 2013
  • Eastern District of Kentucky (859) 233-2661
FRANKFORT—A London, Kentucky cardiologist pleaded guilty to charges that he falsely recorded the severity of patients’ illnesses in order to receive payment for numerous heart procedures.
Sandesh Rajaram Patil, 51, a former cardiologist at St. Joseph’s Hospital in London, admitted Tuesday in Frankfort to making false statements regarding the placement of heart stents. Stents are metal tubes surgically inserted into a patient’s arteries in order to improve blood flow.
Patil reached an agreement with the U.S. Attorney’s Office to serve a prison term between 30 and 37 months, pending a judge’s approval. Patil is scheduled for sentencing on August 27, 2013. St Joseph’s hospital has repaid the government $256,800 for cardiac stent procedures that Patil falsely submitted for reimbursement in 2009 and 2010.
Patil is the third cardiologist in the nation and the first in Kentucky to be federally prosecuted for health care fraud related to the placement of heart stents.
“Dr. Patil violated the public’s trust in physicians,” said Kerry B. Harvey, U.S. Attorney for the Eastern District of Kentucky. “Both patients and the entities that pay for medical services trust that our physicians will accurately and honestly assess a patient’s medical condition. We will aggressively pursue any physician or provider that breaches this trust and places their own financial well-being ahead of the well-being of the patients.”
Under federal law, Medicare and Medicaid reimburse physicians for procedures that are deemed medically necessary. For a cardiac stent procedure to qualify as a medical necessity, it is generally accepted that a patient must have at least 70 percent blockage of an artery and symptoms of blockage. Patil admitted that he placed stents in arteries that had substantially less than 70 percent blockage. Patil nonetheless recorded blockage of 70 percent or more in patient documents to guarantee payment from Medicare and Medicaid.
Kerry B. Harvey, U.S. Attorney for the Eastern District of Kentucky; Perrye Turner, Special Agent in Charge, Federal Bureau of Investigation; and Jack Conway, Kentucky Attorney General, jointly announced the plea.
The investigation was conducted by the Federal Bureau of Investigation, the Kentucky Attorney General’s Medicaid Fraud Abuse and Control Unit, and the Department of Health and Human Services.

GOP congressman pushes for ‘patient-centered’ health law

The Washington Times

Wednesday, June 5, 2013

Rep. Tom Price, Georgia Republican and a physician, says his health care plan won’t put the government “in charge of a doggone thing.” (Associated Press)
A Georgia congressman said Wednesday that House Republicans will redouble efforts to replace President Obama’s health care law with a “patient-centered” alternative that uses tax breaks to make insurance affordable without imposing mandates on Americans.
Rep. Tom Price, a Republican and a doctor, said he will introduce the “third iteration” of his bill to replace the Affordable Care Act as soon as this week.
Besides using the tax code to put health coverage within reach for poorer citizens, he said his legislation would let people roll over their health insurance from employer to employer, allow people with high-risk diagnoses to pool together for more price leverage and continuity in their coverage, and reduce unnecessary medical services by reforming malpractice litigation.
“You can do all of those things without putting the government in charge of a doggone thing,” he said during a wide-ranging breakfast hosted by The Christian Science Monitor in downtown Washington.
He outlined the legislation in an attempt to prove that Republicans can outline specific health care goals and not just lambast Mr. Obama’s overhaul.
Mr. Price’s alternative bill, like every attempt to repeal or replace “Obamacare,” could gain traction in the Republican-led House but will face an uphill battle as long as Democrats control the Senate and White House.
House Minority Leader Nancy Pelosi and other top Democrats have needled House Republicans over their repeated efforts to scrap the law. The chamber’s majority party has called more than 30 votes to repeal all or parts of the law, including one last month that is sure to die on the legislative vine.
“As Speaker [John A.] Boehner has said, the Affordable Care Act is the law of the land,” Pelosi spokesman Drew Hammill said Wednesday. “The American people want solutions from their representatives in Congress, not more silliness. It’s time to drop the partisan games and focus on economic growth and jobs for the middle class.”
But Mr. Price, echoing a now-famous comment from Senate Finance Committee Max Baucus, Montana Democrat and key author of the health care law, said Mr. Obama’s reforms are heading for a “train wreck.”
“I think what we need to do is pull the emergency brake before the wreck occurs,” he told reporters.
Mr. Price said Congress also is equipped to effectively take on two of the most pressing issues on Capitol Hill — deficit reduction and immigration reform.
On the latter, he said he prefers the piecemeal, or “sequential” approach that is favored by House Judiciary Chairman Bob Goodlatte, Virginia Republican, as opposed to comprehensive efforts underway in the Senate.
He said Congress, despite its partisan rancor, can craft meaningful tax reform and reach a deal on how to reduce the federal deficit, now that both chambers have passed budget plans.
“The mechanism in place allows us to move to the next step, which we haven’t been able to do in the last four years,” he said, noting Budget Chairman Paul Ryan, Wisconsin Republican, and Senate Budget Chairwoman Patty Murray, Washington Democrat, are meeting with “great regularity” to set parameters around a budget conference between the parties so it’s “not just a free-for-all.”
In Mr. Price’s view, a “maturing and coalescing” of the GOP conference has allowed its members to get passed their perceived low-point around New Year’s Day, when fractures among the party’s establishment and a young, conservative wing threatened to derail negotiations on the “fiscal cliff.”
He said he would prefer to settle the nation’s budget issues before they reach the debt ceiling once again. That way, he said they would not be not in a crisis mode, “which tends to be the time when Washington makes the least-responsible decisions.”
“I’m an eternal optimist,” Mr. Price said, “so I always believe things are possible, even in this town.”

Arizona insurers must pay for telemedicine

Senior Reporter-Phoenix Business JournalJun 4, 2013, 6:00am MST

Gov. Jan Brewer has signed the Telemedicine Reimbursement Parity Act into law, requiring telemed services in rural areas of Arizona to be covered by health insurance.
Beginning in 2015, insurers must cover services provided through the telemedicine service programs if the insurers pay for those same services when they are provided in a traditional clinic or hospital setting.
The Arizona Legislature established the Arizona Telemedicine Program in 1996, which now links 70 Arizona communities at 160 sites, said Dr. Ronald Weinstein, co-founder and director of the program.
“Our telemedicine program is a critical link to health care,” he added. “We primarily are devoted to improving access to specialized medical care throughout the state of Arizona.”
The new law defines telemedicine services as the delivery of health care, diagnosis, consultation and treatment, and the transfer of medical data through interactive audio, video or data communications that occur in the physical presence of the patient.
Kathi Beranek, manager of government relations and public policy for Blue Cross Blue Shield of Arizona, said BCBS worked closely with advocates on the terms of the bill.
“Looking toward 2015, the bill will allow more people, especially in rural communities, access to better care combined with potential cost savings,” she said.

Telemedicine Revenues Grew 237 Percent in Five Years, According to a New Kalorama Information Report

PRWeb | June 5, 2013

The telemedicine patient monitoring market grew from 4.2 billion in 2007 to over 10 billion dollars in 2012, according to Kalorama Information. The healthcare market research publisher said that while the market is small, it is fast growing with a large amount of competitors and increasing awareness of effectiveness.
New York, New York (PRWEB) June 05, 2013
The telemedicine patient monitoring market grew from 4.2 billion in 2007 to over 10 billion dollars in 2012, according to Kalorama Information. The healthcare market research publisher said that while the market is small, it is fast growing with a large amount of competitors and increasing awareness of effectiveness. The finding was made in Kalorama Information’s newly published report, “Advanced Patient Monitoring Systems.”
Kalorama defines telemedicine as a patient monitor used outside of an acute healthcare setting that can transmit vital signs or other information to a healthcare professional for interpretation or action, usually from a patient’s home. Two-way communication in audio or video, EMR data transfer advanced diagnostics are among the additional features that some of these devices provide. Unlike the market for systems used in hospitals, this market is more competitive and vendors are fragmented with a fair number of privately held companies. Compatibility between devices and applications is of primary concern. AMD, Philips, Second Opinion Telemedicine, Bosch, LifeWatch are among the many vendors operating in this market.    The aging of the population, increasing healthcare costs, dwindling healthcare resources, advancing technologies, and the proven cost effectiveness of patient monitoring. The report says that sales will be driven in new technologies as older monitoring equipment is replaced by wireless or remote monitors. Growth will increase over the forecast period as compatibility, privacy, and security issues continue to be resolved.
“The home healthcare and remote location health monitoring market is different from the hospital market, in large part because reimbursements are lower or are just beginning to take hold, and for some products are still nonexistent,” said Melissa Elder, Kalorama analyst and the author of the report. “Unit costs will go up as older units are replaced with wireless, handheld, and ambulatory devices.”
Elder adds that home healthcare markets vendors sell lower-priced units than hospital patient monitors but the key for successful vendors will be selling a volume. The report also indicates that the U.S. holds the largest share of the market and will be the battleground for a lot of the regulatory and reimbursement challenges for these technologies. Yet telemedicine is a worldwide market. Switzerland, for example, has prepared the health system for telemedicine options with an advanced IT infrastructure and healthcare staff trained in high-tech medical technology. Economic struggles in many European countries, including Germany, have forced the government to review options to control costs in the healthcare system which will present opportunities for telemedicine. France is facing some of the same issues as other European countries, though there are barriers. A World Health Organization overview of the French healthcare system in noted that providing care using Telemedicine would require a new legal framework. It has since developed new policies to help professionals obtain reimbursement and provide a newer method of healthcare delivery.
Kalorama’s market research study in this market, “Advanced Patient Monitoring Systems”, contains both a global and US market estimate and forecast for advanced remote patient monitoring systems. The report covers key trends in the industry and profiles several key players in the market. The report can be purchased at Kalorama Information at
About Kalorama Information
Kalorama Information, a division of, supplies the latest in independent medical market research in diagnostics, biotech, pharmaceuticals, medical devices and healthcare, as well as a full range of custom research services. We routinely assist the media with healthcare topics. Follow us on Twitter, LinkedIn and our blog.
For the original version on PRWeb visit:

Aetna and Beacon Health Partners, LLP Build Medical Home Program

Published: June 7, 2013 

Re — Aetna (NYSE: AET) and Garden City-based Beacon Health Partners, LLP today announced a new agreement to reward Beacon’s independent practices for operating as Patient-Centered Medical Homes (PCMHs).
“The PCMH model of care is designed to reward physicians for delivering better coordinated, higher quality and more efficient care, which will result in an improved overall value and patient experience for our members,” said David Kobus, Aetna’s senior vice president of Network Management for New York.
A medical home is a team of doctors and clinicians within a medical practice who work together to provide continuous and comprehensive health care for patients. By providing proactive and ongoing attention, rather than episode-based treatment, doctors in a medical home can provide more efficient and more effective care.
“Medical homes can support improvements in care quality, positively impact member health, and reduce medical costs through better efficiency and data sharing,” said Terry Golash, M.D., Aetna senior medical director. “Medical homes allow for improved information exchange and communication among physicians, other care providers, patients and insurers, all of which help enable informed clinical decisions.”
The two-year initiative rewards Beacon for continued and improved patient care coordination and outcomes in categories such as cancer screening measures and diabetic or cardiovascular monitoring and care. Aetna and Beacon also will share data to support appropriate patient care.
Dr. Simon Prince, President of Beacon said, “Doctors often talk about quality, but don’t measure it. One of the key characteristics of the medical home is that it brings rigorous measurement and quality analysis to prove that the best care is being provided, resulting in fewer hospitalizations and medical errors.”
About Beacon Health Partners
Beacon Health Partners, based in Garden City, NY, is a physician-owned Accountable Care Organization (ACO). Made up of primary care physicians and specialists, Beacon’s mission is to improve quality of care through a new, improved care management system that allows greater focus on patient wellness, reducing time spent on more expensive treatments. Beacon has more than 300 physicians dedicated to providing coordinated, efficient, quality patient care at its numerous locations across Long Island, Queens, Brooklyn and Manhattan. The practice uses state-of-the-art systems and electronic medical records to enhance the health of the community. For more information, visit us at
About Aetna
Aetna is one of the nation's leading diversified health care benefits companies, serving an estimated 44 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid health care management services, workers' compensation administrative services and health information technology services. Aetna’s customers include employer groups, individuals, college students, part-time and hourly workers, health plans, health care providers, governmental units, government-sponsored plans, labor groups and expatriates. For more information,

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