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Criminal and Civil Enforcement

January 2007 Criminal Enforcement Report

Practitioners

In Michigan, a dentist was sentenced to 15 months in prison and ordered to pay $147,000 in restitution and a $50,000 fine for health care fraud. The dentist's husband was ordered to pay almost $10,000 for making a false statement. The dentist submitted or caused to submit claims to insurers for services that were not rendered. The investigation revealed that claims were for services rendered when the dentist was on travel or purportedly rendered by the former owner of the practice who had been deceased since January 1996. In addition to the fraud scheme, it was revealed that the dentist, who had been diagnosed with Hepatitis, did not disclose her condition to patients or take certain precautionary measures when treating patients.

In Arizona, a podiatrist sentenced for theft of Government money was ordered to pay $55,000 in restitution. The podiatrist provided non-covered routine foot care services to beneficiaries but billed Medicare as of he performed nail avulsions or debridements.

Durable Medical Equipment

In Idaho, a man was sentenced to 4 months imprisonment, 4 months home confinement and ordered to pay a $5,000 fine for conspiracy. The man, who worked for a DME supplier, orchestrated a Medicare fraud scheme that included falsifying and forging certificates of medical necessity for oxygen services and supplies.

Public Health Related

n South Dakota, an attorney was sentenced to 3 months incarceration and ordered to pay $9,000 in restitution for health care fraud and false claims. The attorney falsely claimed to be part Native American Indian so she could receive free health care services from the Indian Health Service.

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February 2007 Criminal Enforcement Report

Practitioners

In Florida, a physician was sentenced to 24 months incarceration and ordered to pay $727,000 in restitution for his involvement in a health care fraud scheme. For cash payments, the physician signed blank prescriptions and certificates of medical necessity for patients he never saw. In turn, co-conspirators submitted claims to Medicare for DME and other items or services that were either not medically necessary or were not provided to beneficiaries.

Home Health Agency

In Ohio, the former owner of a home health company was sentenced to 13 years incarceration and ordered to pay $564,000 in restitution for health care fraud, money laundering, and for drug and weapons charges. Investigation revealed that the man solicited a population of the immigrant community to provide unnecessary medical services and billed Medicaid for those services. To facilitate the fraud, doctors signed plans of care to indicate that patients were in need of skilled nursing and home health aid services. In reality, patients had not been seen by the doctors. In addition, reimbursements from claims submitted to Medicaid were diverted to support his drug habit and to fund personal business ventures.

Employee Misconduct

In Arizona, a former IHS employee was sentenced to 6 months home confinement and ordered to pay $66,000 in restitution for theft and embezzlement in connection with health care. While employed as a secretary at an IHS medical facility, the man stole checks that were made payable to the Indian Health Service.

Child Support Enforcement

In Florida, a woman was ordered to pay a $500 fine for failure to pay child support. Prior to entering her guilty plea, the woman paid her arrearage amount of approximately $40,500. Though she was gainfully employed, the woman had not made a single voluntary child support payment since 1995.

Durable Medical Equipment

In Tennessee, the owner of a Texas durable medical equipment supplier was sentenced to 18 months in prison and ordered to pay $432,000 in restitution for violating the anti-kickback statute. Investigation revealed that the owner paid kickbacks of $1,000 for each certificate of medical necessity (CMN) she received. The CMNs were then used to bill Medicare for motorized wheelchairs for patients who had no need for the wheelchair. Patients either received no wheelchair at all or were provided with a less expensive scooter.

Other Cases of Interest

In Michigan, an attorney specializing in health care law was sentenced to 13 months incarceration and ordered to pay $98,000 in restitution for mail fraud. The attorney was hired by a physician group to negotiate a contractual joint venture agreement with a physical therapy company. As part of the negotiations, he was tasked with obtaining an official advisory opinion from OIG to ensure that the arrangement would not violate the anti-kickback statute. However, he did not request and obtain an advisory opinion from OIG but instead prepared false documents on copied OIG letterhead which falsely stated the joint venture met with the approval of OIG.

Home Health

In Virginia, a personal care aide, who devised a scheme to defraud the Medicaid program, was sentenced to 5 months in jail and ordered to pay $58,000 in joint and several restitution. Three co-defendants were previously sentenced for their involvement in the fraud scheme and held jointly liable for the restitution amount. The personal care aides caused the Medicaid program to pay for services not rendered by falsifying time sheets and personal care aide logs.

Prescription Drug Fraud

In West Virginia, pursuant to his guilty plea, a physician was sentenced to 1 month imprisonment and ordered to pay a $5,000 fine for obtaining prescription drugs by fraud. The physician was also ordered to participate in a program of testing, counseling, and treatment for drug and alcohol abuse. The physician used drug samples that he obtained from pharmaceutical companies for his own personal use.

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April 2007 Criminal Enforcement Report

Home Health

In Ohio, a former owner of a home health agency was sentenced to 97 months in prison and ordered to pay $2.7 million in restitution pursuant to her conviction for her scheme to defraud the Government. The investigation revealed that from October 2001 through May 2003, Medicaid was billed for skilled nursing services that were not rendered as claimed. The woman billed for 14 hours of services per week when actually only 1 hour or less of services was provided per week. During the trial, it was also revealed that the woman instructed employees to falsify nursing notes.

Practitioners

In Washington D.C., a doctor was sentenced to 5 months incarceration and ordered to pay $155,000 in restitution for health care fraud. From October 2001 through March 2003, the doctor submitted claims to Medicare for Reteplase injections that were not given. Reteplase is a drug generally given in a hospital emergency room within the first three hours of a patient experiencing myocardial infarction (commonly referred to as a “heart attack”). The doctor submitted claims for one patient who purportedly had been injected 119 times.

In Illinois, a licensed speech-language pathologist was sentenced to 6 months home detention and ordered to pay $60,000 in restitution for health care fraud. From January 2001 to September 2002, the speech-language pathologist billed the Medicaid program for services that were not provided. The investigation revealed that the woman altered or caused to be altered records to reflect therapy services that were not provided.

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May 2007 Criminal Enforcement Report

Kickbacks

In Tennessee, the owner of a physical therapy company pled guilty to violating the anti-kickback statute and was sentenced to 4 months in prison and ordered to pay $173,000 in restitution. The woman paid kickbacks to doctors based on the percentage of her profits for the patients referred to her company for physical therapy services. During the investigation, it was also revealed that the woman employed unlicensed physical therapists, billed for more therapy than was provided, and prepared fraudulent medical records for a Medicare audit.

Practitioners

In Oklahoma, a physician was sentenced to 33 months in prison and ordered to pay $544,000 in restitution for health care fraud. From January 2000 to May 2005, the physician billed for dosages of Remicade and Procrit which far exceeded the amount of those drugs in his inventory.

In Tennessee, a psychologist was sentenced to 5 months in prison, 5 months home detention and ordered to pay $63,000 in restitution for his scheme to defraud Medicare and Medicaid. The psychologist billed Medicare and Medicaid for services provided to beneficiaries at nursing homes that were not rendered. Some of the services billed were for dates of service that occurred after the beneficiaries' date of death or were for dates of service when the psychologist was not at the nursing home.

Medicaid Fraud

In California, a man was sentenced to 18 months imprisonment and ordered to pay $140,000 in restitution for mail fraud. The investigation revealed that the man submitted false information to obtain benefits for which he was not entitled including In-Home Support Services, an HHS-funded program.

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June 2007 Criminal Enforcement Report

Practitioners

In Massachusetts, a licensed practical nurse (LPN) was sentenced to 63 months in jail and ordered to pay $1,500 in fines and restitution for health care fraud and tampering with consumer products. While working at a nursing home, the LPN took pills that were prescribed to Medicaid patients for his own personal use. The investigation revealed that the LPN removed pills from blister cards, replaced them with pills that resembled what he took, and then used superglue to reattach the backing of the blister card.

Durable Medical Equipment

In Texas, a man was sentenced to 80 months incarceration and ordered to pay over $2 million for his involvement in a motorized wheelchair scheme. The man, who was found guilty after a 6-week trial, fraudulently marketed wheelchairs. As part of the scheme, the man transported over 500 Medicare beneficiaries from Louisiana to a Texas clinic. For each beneficiary he brought to the clinic, he received between $200 and $1,000 from various durable medical equipment suppliers. At the clinic, one of three doctors performed a psychiatric evaluation on beneficiaries and then signed certificates of medical necessity and prescriptions for wheelchairs.

Misuse of Grant Funds

In California, a woman was sentenced to 1 year in a county jail and ordered to pay $112,000 in restitution for her scheme to embezzle Government funds. While employed as an accounting clerk with the California Prevention and Education Project (CAL-PEP), the woman issued 46 unauthorized CAL-PEP checks to herself and to another individual. A program that receives HHS funds, CAL-PEP provides a broad range of services to people affected by HIV/AIDS.

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July 2007 Criminal Enforcement Report

Practitioners

In Florida, a doctor was sentenced to 78 months in prison and ordered to pay $504,000 in restitution and forfeit an additional $705,000 after a jury found her guilty on all counts of an 89-count indictment including 44 charges of health care fraud. The female physician, who practiced dermatology, billed Medicare as if she performed highly complex surgical closure procedures when she actually only performed simple surgical stitches or no procedure at all.

Durable Medical Equipment

In Florida, three subjects were sentenced for their roles in a scheme to submit false claims to Medicare for medically unnecessary DME. The DME company owner was sentenced to 63 months in jail; his wife was sentenced to 6 months of home confinement. As part of the scheme, the company owner paid Medicare beneficiaries for the use of their Medicare numbers in order to submit the false claims. In addition, a physician was paid for fraudulent prescriptions for the medically unnecessary DME. For his involvement in the scheme, the physician was sentenced to 36 months in jail. The 3 subjects were ordered to pay $1.3 million in joint and several restitution.

In New York, a man was sentenced to 15 months incarceration (time served) and ordered to pay $334,000 in restitution for his involvement in a health care fraud scheme. The man, who owned a durable medical equipment (DME) company, was involved in a scheme involving staged motor vehicle accidents. As part of the scheme, individuals were paid to participate in staged accidents so patients could be given DME and be referred for treatments that were not provided and/or not necessary. In turn, insurance companies were billed for fraudulent claims.

In Pennsylvania, a DME company owner/operator was sentenced to 6 months home detention and ordered to pay $31,000 in restitution for health care fraud. The man billed the Medicare program for prosthetic limbs and other DME that was never provided to beneficiaries.

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August 2007 Criminal Enforcement Report

Practitioners

In Washington D.C., an ophthalmologist was sentenced to 18 months in prison, 6 months home detention and ordered to pay over $1 million in restitution and a $50,000 fine for health care fraud and filing a false tax return. The ophthalmologist billed Medicare, other Federal health care programs and private insurers for services either not provided or not medically necessary. In addition, the ophthalmologist paid personal expenses and salaries to his children and housekeeper with funds from his medical practice and falsely recorded these payments on corporate records as legitimate business expenses. He also took charitable deductions on his income tax returns for contributions he made to a non-profit organization that were used, in part, to pay for a family vacation.

Transportation Fraud

In West Virginia, a woman and her billing company were sentenced related to a scheme to submit false claims to the Medicaid program. The billing company was sentenced to 5 years probation and ordered to pay $353,000 in restitution; the owner of the billing company was ordered to pay a $500 fine. The investigation revealed that the Medicaid program was routinely billed twice for each ambulance transport service provided.

Employee Misconduct

In North Carolina, a former Regional Administrator for the Centers for Medicare & Medicaid Services (CMS) was sentenced to 180 days of home detention and ordered to pay $60,000 in restitution and a $5,000 fine for false statements to obtain Federal employee's compensation. In addition, she entered into a settlement agreement and agreed to pay an additional $80,000. The former CMS employee was allegedly injured at work in 1999 and until the end of 2006 received a total of $270,000 from the Department of Labor's Office of Workers' Compensation Program. An investigation revealed that approximately from January 31, 2002 through January 31, 2006, she knowingly and willfully withheld employment information and provided false statements on documents submitted to the Department of Labor in order to receive disability compensation. Though she claimed to be partially disabled, the woman owned and ran a bed and breakfast where she performed nearly all aspects of operating the business including landscaping and cooking.

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September 2007 Criminal Enforcement Report

Practitioners

In Pennsylvania, a licensed physical therapist was sentenced to 6 months incarceration and ordered to pay over $1.2 million in restitution for health care fraud. An investigation revealed that the physical therapist submitted claims to Medicare from January 2000 through December 2002 for physical therapy services not rendered or not rendered as billed. Some of the claims filed were for dates of service that would have required him to work more than 24 hours in a day. In Hawaii, a physician was sentenced to 1 year and 1 day in prison and ordered to pay a $10,000 fine for dispensing Oxycodone outside the course of professional medical practice and for no legitimate medical purpose. An investigation revealed that the physician was illegally prescribing Oxycodone. The physician will be deported to Canada upon completion of his prison sentence.

Transportation Fraud

In Virginia, an owner of a transportation business was sentenced to 12 months and 1 day in prison and ordered to pay $136,000 in restitution for health care fraud. The man's business provided transportation services to the District of Columbia's Medicaid recipients. An investigation revealed that from approximately November 2002 through May 2006, the Medicaid program was billed for non-emergency transportation services that were not rendered some of which were for dates of service that occurred after the beneficiaries' date of death.

Durable Medical Equipment

In Pennsylvania, a man was sentenced to 37 months in prison and ordered to pay over $1.6 million for transporting stolen goods in interstate commerce. The man stole 66 colonoscopes from 22 different hospitals throughout Pennsylvania, New York, West Virginia, Ohio and Indiana and then sold the equipment to various medical equipment companies.

Child Support Enforcement

In Florida, a man was sentenced to time served of 4 months, 1 year of supervised release and ordered to pay $25,000 in restitution for failure to pay child support. The man, who owed support for two different children by two different women, avoided paying his support obligation by quitting jobs once wage withholding orders were in place. One of his children was diagnosed with Attention-Deficit/Hyperactivity Disorder and has a learning disability.

Public Health-Related Investigation

In Oregon, a woman was sentenced to 6 months of home detention and ordered to pay $50,000 in restitution for fraudulently obtaining money from the Ricky Ray Hemophilia Relief Fund Program. The woman submitted a false application to the Health Resources and Services Administration purporting that she was the surviving child of an eligible Ricky Ray Relief Fund recipient. The fund provides for payment to certain individuals or the survivors of certain individuals with a blood-clotting disorder who may have contracted HIV from a blood transfusion.

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October 2007 Criminal Enforcement Report

Durable Medical Equipment

In Florida, the owner of durable medical equipment (DME) company was sentenced to 151 months in prison and ordered to pay $3.4 million in restitution. The man was convicted by a Federal jury for his scheme involving fraudulent prescriptions for non-commercially available aerosol medications so that they could be illegally "compounded." Compounding is a process of a pharmacist making the medication as opposed to a pharmaceutical manufacturer. The non-approved medications were then billed to the Medicare program. Pharmacy owners involved in the scheme returned half of the Medicare reimbursement to the DME company owner for each fraudulent prescription. Patients and physicians involved in the fraud scheme were also paid cash kickbacks.

In Arizona, a DME company owner was sentenced to 3 years in prison and ordered to pay over $680,000 in restitution for his fraudulent billing scheme. The man opened a storefront DME supplier that was never open to the public yet Medicare was fraudulently billed for DME that was never ordered or provided to beneficiaries. As a result of the investigation, approximately $431,000 was seized and forfeited to the Government.

Transportation Fraud

In Indiana, the operator of a transportation company was sentenced to 8 months in prison and ordered to pay $65,000 in restitution for health care fraud. The man billed the Medicaid program for non-emergency transportation services as if beneficiaries were wheelchair bound when they were not. The man, who was previously convicted in Georgia on similar charges, is facing deportation to Africa.

Employee Misconduct

In Maryland, a former NIH employee was sentenced to 45 days in prison and ordered to pay $24,000 in restitution for theft of Government property. Throughout a 2-year period, the woman used her Government-issued credit card to make unauthorized purchases for personal items including a laptop computer, shoes, clothing, and furniture. She also used the credit card for unauthorized travel and travel-related expenses.

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November 2007 Criminal Enforcement Report

Psychiatric and Psychological Services

In Pennsylvania, an owner/operator of a mental health facility was sentenced to 5 years in prison and ordered to pay over $280,000 in restitution and fines after being found guilty on all charges contained in a 49-count indictment. The woman and her company fraudulently obtained individual and group provider identification numbers from Medicare and then used those numbers to submit false and fraudulent claims for psychiatric and psychotherapy services. An investigation revealed that services were not rendered as billed or provided by licensed professionals.

Prescription Drug Fraud

In Virginia, a man received a 32-year suspended prison sentence provided he serve 10 days in jail and was ordered to pay $1,200 in restitution for obtaining prescription drugs by fraud and identity theft. Between January and August 2006, the man used an illegally-obtained Medicare Part D prescription card at pharmacies located in Virginia and Tennessee to obtain Schedule III and IV pain medications. The prescription card belonged to a Virginia beneficiary unknown to the defendant.

Clinics

In Florida, a woman was sentenced to 54 months in jail and ordered to pay $3.3 million in restitution for her involvement in a health care fraud scheme. The woman, who owned and operated a clinic, billed Medicare for fraudulent infusion therapy services and paid kickbacks to beneficiaries for the use of their Medicare number in order to fraudulently bill Medicare.

Durable Medical Equipment

In Florida, the owner of a durable medical equipment (DME) company was sentenced to 30 months in jail and ordered to pay $1.4 million in restitution for health care fraud. From April 2006 through October 2006, the DME company owner fraudulently billed Medicare for DME that was never ordered by physicians or provided to beneficiaries.

Practitioners

In Ohio, a podiatrist was sentenced to 1 month in jail, 6 months of home detention and ordered to pay $120,000 for health care fraud. The podiatrist submitted claims to Medicare and Medicaid using another podiatrist's provider number in order to circumvent an offset for overpayment he owed Medicare for services he provided while he had been excluded. The podiatrist was previously excluded after failing to repay his Health Education Assistance Loan.

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December 2007 Criminal Enforcement Report

Durable Medical Equipment

In Connecticut, pursuant to his guilty plea, an owner of two hearing aid stores was sentenced to 12 months and 1 day in prison and ordered to pay $151,000 in restitution for health care fraud. The investigation revealed that the man submitted claims to private insurers for hearing aid products and/or services that were false. In addition, the man is facing State level charges for defrauding the Medicaid program for the same type of billing scheme.

Practitioners

In Georgia, a respiratory therapist was sentenced to 5 years in prison and ordered to pay $2.7 million in restitution for conspiracy to commit health care fraud. The respiratory therapist, who worked in a hospital, provided false blood test results for patients so a DME provider could in turn bill Medicare and Medicaid for unnecessary oxygen treatments.

In Colorado, a licensed clinical social worker (LCSW) was sentenced to 6 months of home detention and ordered to pay $63,000 in restitution for mail fraud. The LCSW billed Medicare for counseling services never rendered. Investigation revealed that the LCSW billed for more than 150 dates of services for a beneficiary that she actually only saw once. Medicare also denied claims billed for dates of services for 2 of her patients that occurred after their dates of death.

Medicaid Fraud

In Wisconsin, a woman was sentenced to 5 years in prison and ordered to pay $321,000 in restitution for defrauding the Wisconsin Medicaid program. The woman owned and operated a company that she founded to provide pre-natal and child care coordination services. An investigation revealed that the woman billed the Medicaid program for services never rendered or for non-covered services. In addition, the woman attempted to cover-up the fraudulent billings by paying employees to fabricate records to support the fraudulent claims. Four co-defendants were previously sentenced related to their role in fabricating documents.

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