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Criminal and Civil Enforcement

January 2006 Criminal Enforcement Report

Transportation Fraud

In Virginia, an owner/operator of a non-emergency medical transportation provider was sentenced to 8 months in jail and ordered to pay $21,000 in restitution for health care fraud. The owner/operator defrauded the Virginia Medicaid program by billing for trips for individuals as non-ambulatory when, in fact, they were ambulatory, and for billing excessive mileage.

Employee Misconduct

In Maryland, a former NIH program specialist was sentenced to 9 months home detention and ordered to pay $142,000 in restitution for theft of Government property. The man used his Government-issued credit card to make unauthorized purchases.

Practitioners

In Virginia, a doctor was sentenced for racketeering, illegal distribution of prescription drugs, illegal distribution of marijuana to a patient, and health care fraud. The doctor owned and operated a criminal enterprise where he illegally distributed prescription narcotics, as well as, submitted false claims to Medicare and Medicaid.

Child Support Enforcement

In California, pursuant to his guilty plea, a man was sentenced to 5 years probation, to include 1 year of home detention, and ordered to pay $186,000 in restitution for failure to pay child support. The man, who was a master craftsman/carpenter, provided a false Social Security number to employers, and has not filed taxes for at least the past 5 years.

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February 2006 Criminal Enforcement Report

Durable Medical Equipment

In Texas, the owner of a durable medical equipment (DME) company was sentenced to 63 months in prison and ordered to pay $669,000 in restitution for conspiracy and health care fraud. The man fraudulently billed Medicare for motorized wheelchairs and accessories, and alternating pressure mattresses. Beneficiaries either did not receive any equipment at all or were provided with a less expensive item. In addition, the man paid recruiters between $200 and $500 for beneficiary's personal information.

Practitioners

In Ohio, a podiatrist was sentenced to 78 months incarceration and ordered to pay $528,000 in restitution for conspiracy, health care fraud, and false statements. The podiatrist, after being reinstated to the Medicare program in 2002, billed Medicare for non-covered routine foot care. Patient charts contained no documentation other than the handwritten date of service. In 2000, the Department of Justice recommended that the podiatrist be excluded for failure to repay his Health Educational Assistance Loan. In order to avoid the exclusion, the podiatrist submitted a fraudulent provider application to Medicare listing the owner of his new company as his dying friend, who was also a podiatrist, and began billing under the false identity.

In Virginia, a podiatrist was sentenced to one year and one day in prison for mail fraud. The podiatrist billed for procedures performed at a surgery center when, in fact, the services performed were routine, and performed in the office. The address of the surgery center was actually a mailbox rental business located next to his office. Through his billing scheme, the podiatrist was reimbursed for facility-related charges such as pre-op and post-op rooms.

Child Support Enforcement

In Florida, a man was sentenced to 5 years probation and ordered to pay $47,000 in restitution for failure to pay child support. The man, who was ordered to pay support in 1987, gave numerous reasons for not making his support payments, including that he felt the custodial parent was capable of supporting herself and their minor child. The man's last documented support payment was involuntary and occurred in May 1990. The investigation revealed that the man had changed his last name, and lived in at least four different States after leaving Florida.

Home Health Agencies

In Tennessee, a man who owned a home health agency (HHA) serving Medicare beneficiaries and an agency providing private duty nursing services to non-Medicare beneficiaries was sentenced to 24 months incarceration, part of which will be spent in a half-way house, and ordered to pay a $700 assessment for health care fraud and false statements. A decision on the amount of restitution the man must pay has been deferred. The investigation revealed that the man failed to disclose his nursing service agency as a related party on his HHA's cost reports for years 1998, 1999 and 2000. In addition, costs for nursing services for non-Medicare beneficiaries were shifted to the HHA's Medicare cost reports.

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March 2006 Criminal Enforcement Report

Durable Medical Equipment

In Florida, a licensed orthotist and a patient recruiter were sentenced for conspiring to commit health care fraud involving eight Miami-based medical organizations. The orthotist was sentenced to 28 months in prison and ordered to pay $1.8 million in restitution; he collaborated with DME owners to provide signed documentation for orthotic devices without ever examining the patient. The DME companies then billed for custom-fitted devices when actually, a prefabricated device was provided. The patient recruiter was sentenced to 22 months in prison and ordered to pay approximately $4.2 million in restitution. As the primary recruiter in the scheme, he paid Medicare beneficiaries for the use of their personal information. The information was then provided to six DME companies and to two pharmacies that, in turn, submitted fraudulent claims to Medicare.

Practitioners

In New York, a dermatologist was sentenced to 20 years in prison and ordered to pay $888,000 in restitution for unlawfully distributing prescription narcotic drugs and health care fraud. In addition, a jury found that the dermatologist's conspiracy to distribute prescription narcotics resulted in the death of a patient. The patient, who died from an overdose of Dilaudid, saw the dermatologist approximately 24 times each month. Investigation revealed that for each visit, the dermatologist billed Medicare for excisions of benign growths that were never performed. Although Medicare was billed for over 2,000 surgeries, the patient had no scars. It was revealed that the patient allowed the dermatologist to submit the fraudulent bills, in exchange for prescriptions for controlled substances and monthly cash payments of $700.

Child Support Enforcement

In South Dakota, pursuant to his guilty plea, a man was sentenced to 5 years probation and ordered to pay $22,000 in restitution for failure to pay child support. After his November 2005 arrest, he paid over $4,000 towards his child support arrearage.

Prescription Drug Fraud

In Pennsylvania, three subjects were sentenced for their involvement in conspiring to illegally import prescription drugs from the United Kingdom. The subjects were each sentenced to 6 months home confinement and ordered to pay various fines totaling $50,000. Through their company, the subjects introduced illegally imported drugs, engaged in wholesale distribution of prescription drugs without a Pennsylvania license, and imported drugs not approved by the FDA. The drugs were then billed to and paid for by Medicare and private insurers. As part of the scheme, the subjects took orders for oncology medications from medical practices and had the orders filled through a pharmaceutical distributor in England. To avoid FDA and Customs authorities, the imported drugs were packaged in plain boxes with no return address and without the required Customs declaration.

Misuse of Grant Funds

In Washington, a former State Government social worker and his wife were sentenced related to their scheme to defraud the Government. The man was sentenced to 46 months in prison and ordered to pay $136,000 in restitution; his wife received a 30-day sentence. Between March 1998 and December 2004, the defendants diverted money from a Federally funded program designed to help developmentally disabled foster care children and their families. As part of the scheme, phony invoices were submitted through the man's non-existent business purportedly for services provided to children.

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April 2006 Criminal Enforcement Report

Durable Medical Equipment

In Texas, a physician was sentenced to 10 years in prison and ordered to pay almost $13 million in restitution for her involvement in a motorized wheelchair scheme. The physician and her office manager sold fraudulent certificates of medical necessity and prescriptions for motorized wheelchairs and other durable medical equipment (DME). In addition, the physician and her staff were involved with drug dealers in providing fictitious prescriptions for controlled substances that were filled at area pharmacies. For her involvement, the office manager received a 7-year prison sentence.

Also in Texas, pursuant to her guilty plea, a woman was sentenced to 30 months in prison and ordered to pay $253,000 in restitution for health care fraud. The woman and her husband, who owned and operated a DME company, fraudulently billed Medicare and Medicaid for power wheelchairs and other equipment that was either not provided or prescribed by a doctor. The husband was previously found guilty for his involvement in the scheme and was sentenced to 33 months in prison and ordered to pay $286,000 in joint and several restitution.

Employee Misconduct

In South Dakota, a former Indian Health Service employee was ordered to pay $4,000 in restitution for larceny. The woman allegedly caused the destruction of Government records to conceal payments made to contractors in violation of Federal law. During this investigation, it was revealed that in her capacity of treasurer, she stole funds from the Rosebud Public Health Service Employee Association.

Child Support Enforcement

In Montana, a man was sentenced to 250 hours of community service and 1 year probation for failure to pay child support. He was also ordered to pay $348,000 in restitution, representing his past due arrearage as well as future amounts owed.

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May 2006 Criminal Enforcement Report

Durable Medical Equipment

In Texas, an osteopath was sentenced to 10 years in prison and ordered to pay $7.9 million in restitution for health care fraud and conspiracy. The osteopath signed preprinted prescriptions for motorized wheelchairs and certificates of medical necessity for beneficiaries she never saw. The documents were then provided to durable medical equipment company owners for $250 each.

Practitioners

In California, an audiologist was sentenced to 78 months in prison and ordered to pay $868,000 in restitution for her scheme to defraud. From January 1997 through July 2003, she billed Medicare and Medi-Cal for hearing aids, speech therapy and other related services without being licensed to dispense or render the service and in most cases, without a prescription from a referring physician. In addition, she billed for services purportedly provided to deceased beneficiaries.

In Michigan, pursuant to his guilty plea, a certified social worker (CSW) was sentenced to 100 hours of community service and ordered to pay $356,000 in restitution for health care fraud. Investigation revealed that the CSW billed Medicare and a private insurer for psychotherapy services that were never rendered.

Kickbacks

In Florida, a woman was ordered to pay $17,000 in restitution for her involvement in a kickback scheme. The woman paid kickbacks to an assisted living facility owner in exchange for allowing companies that she represented to provide services to the residents at the facility. Investigation revealed that the services that were being provided were billed as physical and occupation therapy however, the sessions typically only involved the therapists massaging and applying lotion to the beneficiaries' shoulders. In addition, the woman paid kickbacks related to providing medically unnecessary medical equipment to residents.

Transportation Fraud

In North Carolina, an ambulance company and its owner were sentenced related to billing Medicare and Medicaid for dialysis patient transports that were not medically necessary. The owner was sentenced to 120 months in jail for health care fraud and to an additional 31 months in jail (to be run consecutively) for obstruction. The company and the owner were also ordered to pay $604,000 in joint and several restitution. Investigation revealed that emergency medical technicians were instructed to enter false information on ambulance reports falsely indicating patients required an ambulance when, in fact, they did not and could have been transported by other means. The owner also instructed billing personnel to submit claims indicating that patients were bed-confined when, in fact, they were not bed-confined. In addition, prior to an audit, the owner and the billing manager changed records to indicate medical necessity. The owner also intentionally withheld subpoenaed documents. The billing manager was previously sentenced and was ordered to pay $30,000, a portion of the joint and several restitution amount.

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June 2006 Criminal Enforcement Report

Home Health Agency

In Virginia, a woman was sentenced to 2 years probation for making a false statement related to a health care benefit program. The woman falsely certified that personal care aides received 40 hours of training when, actually, most of them received 10-15 hours of training or no training at all. The false certificates resulted in numerous false claims being submitted to the Virginia Medicaid program.

Practitioners

In Ohio, a pain management physician, who was previously convicted in a jury trial, was sentenced to life imprisonment for health care fraud that resulted in the death of two patients. The physician was also sentenced to additional jail time totaling 20 years for illegal drug distribution, mail fraud, wire fraud and health care fraud. If the life sentence is overturned, he will be subject to supervised release and deportation. The investigation revealed that the doctor gave painful trigger-point injections to patients in exchange for prescriptions for narcotic drugs. In turn, the doctor submitted claims to health care benefit programs falsely indicating that he performed a more complex procedure such as nerve block or epidural injections. Many of the patients endured the painful treatments because they were addicted to drugs while other patients, who initially had legitimate injuries, fell victim to the physician's scheme and became addicted to drugs.

In Ohio, a podiatrist was sentenced to 5 months incarceration, 5 months home detention and ordered to pay $120,000 in restitution for health care fraud. The podiatrist billed Medicare and Medicaid for performing surgical procedures on patients when she actually only provided routine foot care.

Child Support Enforcement

In West Virginia, a man was sentenced to 12 months imprisonment, 1 year of supervised release and ordered to pay $76,000 in restitution for failure to pay child support. For three years, the man avoided arrest and prosecution by moving around the country. In November 2005, the U.S. Marshal's Service arrested the man in Louisiana.

In Louisiana, a man was sentenced to 8 months home confinement, 4 years probation and ordered to pay $24,500 in restitution for failure to pay child support. The investigation revealed that the man frequently moved, changed jobs when wage garnishments were in place, and used his new wife's name to open up a business in order to avoid paying his support obligation. The man and his new wife have four children who attend private school while his son in Louisiana received public assistance.

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July 2006 Criminal Enforcement Report

Medicaid Fraud

In Maine, a man was sentenced to 6 months home confinement and ordered to pay $77,700 in restitution for causing another to file a false statement. Although the man was excluded from participating in Federal health care programs, he sought and received employment with a facility that received Medicaid program funds. By failing to disclose that he was an excluded individual, the facility's cost reports included unallowable salary and benefit costs. The facility terminated the man after learning of his exclusion.

Employee Misconduct

In Georgia, pursuant to her guilty plea, a former Senior Executive Service (SES) employee was sentenced for theft of Government property. The woman, who was a senior management official at the Centers for Disease Control and Prevention (CDC), was sentenced to 480 hours of community service and ordered to pay $10,000 in restitution and fines. Through a CDC audit, questionable charges on 34 travel vouchers were discovered. Subsequently, the OIG investigation revealed that the woman concealed fraudulent personal charges and claimed them on her travel vouchers as official business expenses. Many of the charges she labeled as fax, photocopy, or business center charges were actually for room service.

Child Support Enforcement

In Indiana, a man was sentenced to 15 months in prison and ordered to pay $47,000 in restitution for failure to pay child support. The man was the owner/operator of several debt consolidation businesses but routinely failed to pay support for his two children.

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August 2006 Criminal Enforcement Report

Durable Medical Equipment

In Tennessee, a man was sentenced to 23 months in prison and ordered to pay $1.8 million in restitution for his scheme to defraud Medicare. The man controlled a group of durable medical equipment suppliers that billed Medicare for enteral nutrition products for tube-fed patients who were not tube-fed. Enteral supply kits that were not provided were also billed to Medicare to give the appearance that the patients were tube-fed. The man, along with a co-conspirator, recruited friends and family members to open durable medical equipment suppliers in different States in an attempt to avoid detection by Medicare. The nominee owners were paid a percentage of the profits.

In Indiana, a former chiropractor was sentenced to 12 years and 6 months in prison and ordered to pay $1.5 million in restitution for his scheme to defraud the Government. The former chiropractor billed Medicare, Medicaid and private insurers over $1,300 each for medically unnecessary back braces. The braces, which were worth less than $100 each, were distributed to the elderly and the indigent during presentations given at senior centers.

Practitioners

In Michigan, a family practice physician was ordered to pay $194,000 in restitution and fines for mail fraud. The physician prescribed large doses of OxyContin for patients with chronic pain, causing many of the patients to become addicted to the drug. In addition, the physician ignored drug-seeking behavior exhibited by many of his patients. Subsequently, Medicaid and other insurers paid for drugs that were not for a legitimate purpose.

In Ohio, a podiatrist was sentenced to 5 months incarceration, 5 months home detention and ordered to pay $120,000 in restitution for health care fraud. The podiatrist billed Medicare and Medicaid for performing surgical procedures on patients when she actually only provided routine foot care.

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September 2006 Criminal Enforcement Report

Practitioners

In Florida, a physician was sentenced to 46 months in prison and ordered to pay $2.357 million in restitution for her involvement in a kickback scheme. The physician, who entered into a relationship with owners of medical equipment companies, performed cursory examinations of patients referred by the company owners. The physician then signed prescriptions for equipment and medications regardless of medical necessity. The physician received cash kickbacks from the medical equipment company owners based on the reimbursement rate for the item or medication prescribed.

In Georgia, a physician was sentenced to 8 months incarceration and ordered to pay $136,000 in restitution for health care fraud. The physician forged another physician's signature on prescriptions for motorized wheelchairs and submitted false claims to Medicare.

Prescription Drug Fraud

In New York, a pharmacist was sentenced to 55 months in prison and ordered to pay $1.325 million for health care fraud and money laundering. The pharmacist, who formerly owned and operated a retail pharmacy, billed Medicaid and private insurers for prescription refills not authorized by the prescribing physician, billed name brand drugs when generic drugs were provided, and billed for prescriptions that were never actually filled.

Child Support Enforcement

In New York, a man was sentenced to one year and one day incarceration for failure to pay child support. The man paid $160,000 prior to sentencing. The man fled the State in 2002, secreted over $600,000 in assets, transferred assets to relatives, and generated in excess of $125,000 in one year on eBay thereby avoiding any third-party reporting requirements. Further, he hid his whereabouts for approximately 3 years.

In Georgia, a man was sentenced to 5 years probation and ordered to pay $60,000 in restitution for failure to pay child support. The man originally owed over $100,000 in past due support but began making payments totaling approximately $46,000 to show his cooperation during the investigation.

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October 2006 Criminal Enforcement Report

Hospitals, Laboratories and Clinics

In Texas, an owner/operator of a physical therapy clinic was sentenced to 51 months in prison for conspiracy to commit health care fraud. Her co-defendant was previously sentenced to 33 months in prison. In addition, the two were ordered to pay $1.3 million in joint and several restitution. The investigation revealed that from April 1999 through July 2000, claims submitted to Medicare and Medicaid were for physical therapy services that were not performed, or were not performed or supervised by a licensed physician.

Practitioners

In Alaska, a chiropractor was ordered to pay $38,000 in fines and restitution for health care fraud. The chiropractor billed for services that were upcoded, not rendered, and/or delivered by another provider.

Child Support Enforcement

In Michigan, a man was sentenced to 5 years probation and ordered to pay $49,000 for failure to pay child support for his daughter. The man was a professional heavy weight boxer and currently an owner of a record label company. In addition, the man was returned to Georgia to face charges of aggravated assault and battery.

Other Cases of Interest

In Montana, a woman was sentenced to 10 months home detention and ordered to pay $20,000 in restitution for wire fraud and education assistance fraud. The woman used a fraudulent General Education Development Certificate to apply for and receive Indian Health Service, Department of Education, and Department of Interior educational assistance funds for which she was not entitled. This investigation involved OIG, Department of Education, and Department of Interior.

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November 2006 Criminal Enforcement Report

Practitioners

In Arizona, a podiatrist was ordered to pay $400,000 in restitution for his previous guilty plea to theft of Government funds. The podiatrist billed Medicare for debridements when he actually only provided routine foot care, a service not covered by Medicare.

In Pennsylvania, a podiatrist was ordered to pay a $10,000 fine for obstruction of a Federal audit. After a suspicious billing pattern was observed and subsequent Medicare contractor audit was performed, the podiatrist was requested to refund Medicare for claims previously paid. The podiatrist disputed the audit findings and wanted to provide documentation to justify the claims. Knowing he did not possess accurate records, the podiatrist created and back-dated false, fictitious and fraudulent patient treatment records and physician orders to support the previously submitted claims.

Prescription Drug Fraud

In South Dakota, an Indian Health Service (IHS) beneficiary was sentenced to 4 months home confinement for obtaining a controlled substance by fraud. The beneficiary frequented multiple IHS clinics and private health care facilities seeking controlled substances for alleged back and tooth pain.

Child Support Enforcement

In Michigan, a man was sentenced to 16 months imprisonment, 1 year probation and ordered to pay $130,000 in restitution for failure to pay child support. The man worked for a major automaker for approximately 30 years but failed to pay his child support obligation. The man attempted to mitigate his actions by advising the court he had a gambling addiction.

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December 2006 Criminal Enforcement Report

Practitioners

In New York, a dentist was sentenced to 18 months in jail and ordered to forfeit $5 million in assets as a result of being found guilty of defrauding the Medicaid program. The dentist, who became excluded from participating in the Medicaid program in 1995, devised a scheme to maintain his practice which was comprised of 95 percent Medicaid patients. So he could continue treating his Medicaid patients, he hired junior dentists with valid Medicaid provider numbers to perform basic procedures and paid them on a per diem basis. The excluded dentist provided the more complex procedures and billed Medicaid for all the services performed in the practice under the provider numbers of the junior dentists. In an attempt to cover up his scheme, the dentist created management companies so he could deposit the Medicaid funds received that were in the names of the junior dentists.

In Pennsylvania, a radiologic technologist was sentenced to 577 hours of community service and ordered to pay $22,000 in restitution for false statements relating to health care matters. The technologist performed mammograms provided at a clinic without first performing required daily and weekly quality control tests on mammogram machines. As required by Federal law, quality control tests are to be performed to ensure machines are operating within acceptable limits. The investigation revealed that in order to conceal the fraud, the technologist created false records during a 24-week period. As a result, mammograms performed on 577 women could not be considered reliable and the women had to undergo repeat screenings.

Durable Medical Equipment

In Florida, a durable medical equipment (DME) company owner was sentenced to 10 month in prison and ordered to pay $11,000 in restitution for conspiracy to violate the anti-kickback statute. In 2002, the DME company owner entered into an improper relationship with an owner of a pharmacy. The investigation revealed that the DME company owner received illegal kickback payments in exchange for each patient referral.

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