Articles Posted in Home Health Care Fraud

Also known as the “Stark Law,” physician self-referral is a type of health care fraud that a physician may run into when he or she or a family member has a vested interest in another designated health service (DHS). It prohibits a physician from making referrals to these conflicting entities and violations can result in civil money and other penalties.

The Three Points of the Physician Self-Referral Law

The purpose of this law is to prevent a physician from making referrals based upon self-interest rather than the patent’s best interest. When first introduced in 1989 the law only applied to physician referrals to clinical laboratory services. Over the years, Congress has expanded the restrictions to include more designated health services and applied much of the law to the Medicaid program.

Photobucket MIAMI, FLORIDA (AUGUST 10, 2011) – A Miami nurse, Armando Santos, 46, received 10 years imprisonment from his role in a scheme that saw $11 million in fraudulent claims made to Medicare.
Between 2007 and 2009, as an employee of Ideal Home Health company, Santos billed Medicare for services given to Medicare beneficiaries that were either not medically necessary or that were never given, including giving insulin injections to two patients that did not need insulin. Santos worked with the owners of the home health company, Elizabeth Acosta Sanz and Luis Alejandro Sanz in perpetrating the fraud. Of the $11 million in bogus claims filed, $7 million was received.
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Justice.jpgMIAMI, FLORIDA (JULY 27, 2011) – A Miami-based patient recruiter, Vicente Guerra-Nistal, has pled guilty to one count of conspiracy to commit health care fraud before U.S. District Court Judge Joan A. Lenard.

Guerra was part of a 20-member team that scammed Medicare out of more than $25 million. The company for which Guerra worked, ABC Home Health, provided home health services and physical therapy, but the company billed for medically unnecessary services or for services that were never provided. Two physicians, Jose Nunez, M.D. and Francisco Gonzalez, M.D. were also charged in the original February 2011 indictment for prescribing the services.

For his part in the scheme, Guerra recruited participation of Medicare beneficiaries by paying kickbacks and bribes for use of Medicare billing information. As a result of Guerra’s actions, Medicare was billed $194,000. Guerra said he knew that the patients didn’t qualify for the services and that patient records had been altered in order to appear as though they did qualify.

handcuffs-and-calculator-on-headlines-about-white-collar-crime.jpgMIAMI, FL – Yudel Cayro, the owner and operator of Courtesy Medical Group, was sentenced to 5 years behind bars for his role in a wide-ranging Medicare fraud scheme.

U.S. District Judge Adalberto Jordan also ordered Cayro to serve two years of supervised release following his prison term and ordered him to pay $9.8 million in restitution with his co-defendants and co-conspirators in a related case to the Centers for Medicare and Medicaid Services (CMS.)

doctor-writing-prescription.jpgAccording to the Factual Proffer signed by Caryo at the time that he pleaded guilty, he admitted that Courtesy Medical Group operated in part to provide unnecessary prescriptions, plans of care (POC’s) and medical certifications, among other things, to Miami-area home health agencies in return for kickbacks and bribes. Courtesy supplied the fraudulent medical documents so that the home health agencies could bill the CMS for expensive home health services and therapy purportedly for insulin dependent diabetic Medicare beneficiaries. However, the services were not medically necessary and in some cases the beneficiaries did not receive the services.

target-fraud.jpgAs the federal government’s Medicare Fraud Task Force called HEAT (Health Care Fraud Prevention and Enforcement Action Team), left Miami and deployed out across the country in six phases to Houston, Los Angeles, Detroit, Tampa, Baton Rouge and Brooklyn, it seemed many of the initial arrests, particularly out of the Detroit area, had a Miami connection as if the frauds were Miami transplant operations.
Well, finally, a sizeable operation with it seems nary a link to Miami. More importantly, this arrest out of Detroit of 13 people and many of the latest arrests are all pointing towards home health as the priority. Several home health operators and several doctors were arrested in an alleged scheme involving paid patients, false plans of care, and services never performed.
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money%20in%20hand.jpgMIAMI, FL (June 26) – Gladys Zambrana, Javier Zambrana, Enrique Perez, Alejandro Hernandez Quiros aka Alex Hernandez, Vanessa Estrada, Vicenta Tellechea, Modesto Hidalgo and Carlos Castaneda were indicted in connection with an alleged $22 million Medicare fraud scheme operated out of Miami businesses purporting to specialize in home health care services.

Gladys Zambrana was also charged with four counts of health care fraud. Gladys Zambrana and Hernandez Quiros were charged with three counts each of paying health care kickbacks, while Perez, Hidalgo and Tellechea were charged with one count each of paying health care kickbacks. Gladys Zambrana, Perez, Alejandro Quiros, Tellechea and Castaneda were also charged with conspiracy to launder health care fraud proceeds.

According to the indictment, Gladys Zambrana, Perez and Hernandez Quiros operated ABC Home Health Care Inc. (ABC), listing Javier Zambrana as the owner; and Gladys Zambrana and Castaneda operated Florida Home Health Care Providers Inc. (Florida Home Health), listing Tellechea as the owner. Both ABC and Florida Home Health purported to be home health agencies that catered to Medicare beneficiaries. The indictment alleges that at both agencies, beneficiaries were recruited and paid kickbacks and bribes to arrange for their Medicare beneficiary numbers to be used by their co-conspirators to file claims with Medicare for purported home health care services. The indictment alleges that the services were not provided and were not medically necessary.

On March 5, 2009 the Miami Herald reported that “State investigators began sweeps this week targeting fraud and abuse in the home healthcare industry in Miami-Dade, aiming to potentially save millions of dollars in questionable payments by Medicaid.
“They launched a mission to inspect up to 125 home healthcare agencies, about one-third of all Medicaid providers in the county. The providers bill for unskilled workers who are supposed to help homebound patients with bathing, skin care, medication, wound dressing and other basic needs.”
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