Medical Clinic Owners and Patient Recruiters Charged in Miami for Role in $8 Million Health Care Fraud Scheme

WASHINGTON—Several patient recruiters, including two medical clinic owners, have been arrested in connection with a health care fraud scheme involving defunct home health care company Flores Home Health Care Inc. (Flores Home Health).

Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Special Agent in Charge Michael B. Steinbach of the FBI’s Miami Field Office; and Special Agent in Charge Christopher Dennis of the HHS Office of Inspector General (HHS-OIG) Office of Investigations Miami Office made the announcement.

In an indictment returned on September 24, 2013, and unsealed this afternoon, Isabel Medina, 49, and Lerida Labrada, 59, were charged with conspiracy to commit health care fraud, which carries a maximum penalty of 10 years in prison upon conviction. Together with Mayra Flores, 49, and German Martinez, 36, Medina and Labrada also face charges for allegedly conspiring to defraud the United States and to receive health care kickbacks, as well as receipt of kickbacks in connection with a federal health care program, which carry a maximum penalty of five years in prison upon conviction.

According to the indictment, the defendants worked as patient recruiters for the owners and operators of Flores Home Health, a Miami home health care agency that purported to provide home health and physical therapy services to Medicare beneficiaries. Medina and Labrada were also the owners and operators of Miami medical clinics, which allegedly provided fraudulent prescriptions to the owners and operators of Flores Home Health.

Flores Home Health was allegedly operated for the purpose of billing the Medicare program for, among other services, expensive physical therapy and home health care services that were not medically necessary and/or were not provided.

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Medical Clinic Owners and Patient Recruiters Charged in Miami for Role in $8 Million Health Care Fraud Scheme            

Overmedicated?

Millions of Americans place their loved ones in nursing homes every year with the belief that their parents and grandparents will be cared for at all times. Unfortunately, with one out of every three nursing homes cited for abuse across the country, nursing home abuse is a very real problem in the United States. From dehydration and malnutrition to mental and sexual abuse, there are a variety of ways that residents can be mistreated in a nursing home facility. One common way many nursing home or assisted living facility residents can suffer is through overmedication.

One of the most important parts of nursing home care is ensuring nursing home residents are receiving the proper amount of medication at all times. And with the average nursing home resident taking seven to eight different medications a month, this can be a very involved process. Even with federal regulations in place to ensure nursing homes have a system to provide residents with the appropriate amount of medication according to their doctor or pharmacist’s orders, many residents suffer from overmedication every year.

In 2010, statistics from the Centers for Medicare and Medicaid Services (CMS) reported that over 17 percent of all nursing home patients were receiving antipsychotic medications that exceeded the recommended levels on a daily basis. This number has reportedly been as high as 25 percent in the state of California and even a staggering 71 percent in the state of Florida. Even more alarming statistics suggest that close to 40 percent of nursing home residents were given antipsychotic drugs in 2010 even though they were not diagnosed with psychosis.

Unfortunately, a large number of nursing home abuse cases go unreported.
The new trend of using psychoactive medication to control nursing home residents is extremely dangerous. The Food and Drug Administration estimates roughly 15,000 nursing home residents die every year from unprescribed anti-psychotics.

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How to Spot Overmedication in Nursing Homes

Medicare paid $5.1B for poor nursing home care

SAN FRANCISCO (AP) — Medicare paid billions in taxpayer dollars to nursing homes nationwide that were not meeting basic requirements to look after their residents, government investigators have found.

The report, released Thursday by the Department of Health and Human Services’ inspector general, said Medicare paid about $5.1 billion for patients to stay in skilled nursing facilities that failed to meet federal quality of care rules in 2009, in some cases resulting in dangerous and neglectful conditions.

One out of every three times patients wound up in nursing homes that year, they landed in facilities that failed to follow basic care requirements laid out by the federal agency that administers Medicare, investigators estimated.

By law, nursing homes need to write up care plans specially tailored for each resident, so doctors, nurses, therapists and all other caregivers are on the same page about how to help residents reach the highest possible levels of physical, mental and psychological well-being.

Not only are residents often going without the crucial help they need, but the government could be spending taxpayer money on facilities that could endanger people’s health, the report concluded. The findings come as concerns about health care quality and cost are garnering heightened attention as the Obama administration implements the nation’s sweeping health care overhaul.

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Medicare paid $5.1B for poor nursing home care

Quiet deaths don’t come easy

A study finds that Medicare patients near death are increasingly choosing hospice or palliative care over heroic measures in their last days — but that many go through futile hospitalizations and treatments first.

 

February 05, 2013|By Melissa Healy, Los Angeles Times

 

For Americans with a terminal diagnosis, death increasingly comes in the places and ways they say they want it — at home and in the comfort of hospice care.

But for a growing number of dying patients, that is preceded by a tumultuous month in which they endure procedures that are often as invasive and painful as they are futile.

New research finds that the proportion of Medicare patients dying in hospice care nearly doubled from 22% in 2000 to 42% in 2009, an apparent bow to patients’ overwhelming preference for more peaceful passings free of heroic measures. At the same time, though, many of those patients were treated aggressively until days before death seemed inevitable.

Based on the medical and death records of almost 850,000 Medicare patients, the study, published in Wednesday’s edition of the Journal of the American Medical Assn., paints a picture of increasing commotion in the final weeks of patients’ lives.

The patients in the analysis all suffered from the end stages of chronic diseases such as cancer, chronic obstructive pulmonary disease or dementia. But thousands of them endured multiple hospitalizations and treatments before receiving care aimed solely at making their final days comfortable.

During the decade studied, the proportion of patients who spent part of their last month in an intensive care unit grew from 24% to 29%, and the percentage who were hooked to a ventilator rose from 8% to 9%. Among dying patients, the median number of disruptive moves — for example, from nursing home to hospital, from hospital to hospice, from rehabilitation facility to home — grew from 2.1 to 3.1. Among those who spent their final days in a hospice program, 28% were there for under four days.

“I suspect this is not what patients want,” said Dr. Joan Teno, a palliative care physician and professor of health services policy and practice at Brown University, who led the study.

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Quiet deaths don’t come easy

Government takes steps to expose financial ties between drug makers and doctors

WASHINGTON D.C. – After more than a year of prodding from the Senate Special Committee on Aging, the federal government took a major step today aimed at exposing potential conflicts of interests between doctors and drug companies.

The long-awaited rule – drawn from the Physician Payments Sunshine Act – was released late Friday by the Centers for Medicare and Medicaid Services. The rule puts in place a system requiring pharmaceutical and medical device makers to disclose payments and gifts given to physicians. Consumers will have access to the information through a database administered by the U.S. Department of Health and Human Services.

Critics have long contended that the drug industry’s practice of paying doctors influences medical decisions and leads to over-prescribing medicines and patients receiving unnecessary and expensive drug treatments.

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Government takes steps to expose financial ties between drug makers and doctors

Doctor Sued in Huge Prescription Fraud Case

A psychiatrist who lives in Skokie is being sued for orchestrating what federal authorities are calling the largest prescription fraud case ever in Chicago.

The defendant, Dr. Michael J. Reinstein, received illegal kickbacks from pharmaceutical companies and submitted at least 140,000 false claims to Medicare and Medicaid for antipsychotic medications he prescribed for thousands of mentally ill patients in area nursing homes, according to a civil health care fraud lawsuit filed today.

Reinstein also submitted at least 50,000 claims to Medicare and Medicaid, falsely stating that he provided “pharmacologic management” for his patients at more than 30 area nursing homes and long-term care facilities, the lawsuit alleges.

The lawsuit seeks triple damages under the False Claims Act, plus a civil penalty of $5,500 to $11,000 for each alleged false claim.

“This is the largest civil case alleging prescription medication fraud against an individual ever brought in Chicago,” said Gary S. Shapiro, Acting United States Attorney for the Northern District of Illinois.

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Doc Sued in Huge Prescription Fraud Case

Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a Billion Dollars in 2009

Nursing homes are overcharging Medicare to the tune of $1.5 billion annually, a federal report asserts.

The report, titled “Inappropriate payments to skilled nursing facilities cost Medicare more than a billion dollars in 2009,” says that SNFS are upcoding bills to Medicare, either by claiming more services than were done or by giving incorrect treatment.

Under particular scrutiny are physical, occupational and speech therapy, as well as activities of daily living assistance.

A Centers for Medicare & Medicaid Services spokesman told the Wall Street Journal the agency recognizes the overbilling and that doing it “at the expense of taxpayers is unacceptable.” The report, dated Friday, was first reported Tuesday.

Other industry officials have said that nursing homes have upcoded Medicare claims to offset steep Medicaid cuts or losses, and that those days may be coming to an end.
The OIG has bequeathed the name “Operation Vacuum Cleaner” for its look at the issue, the Journal reported. The office has suggested, and CMS agreed with, the following recommendations:

• Increase and expand reviews of SNF claims
• Use of the agency’s Fraud Prevention System to identify SNFs that are billing for higher paying RUGs
• Monitor compliance with new therapy assessments
• Change the current method for determining how much therapy is needed to ensure appropriate payments
• Improve the accuracy of MDS items
• Follow up on the SNFs that billed in error.
CMS concurred with all six recommendations.

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OIG Slams SNFs for Overbilling

Read “Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a Billion Dollars in 2009

FL ALF Owner Sentenced for Medicare Fraud

The owner of a Miami-Dade County assisted living facility (ALF) was sentenced today to 15 months in prison for her role in a kickback scheme that funneled ALF patients to fraudulent mental health providers American Therapeutic Corporation (ATC) and Health Care Solutions Network (HCSN), announced U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; Michael B. Steinbach, Acting Special Agent in Charge of the FBI’s Miami Field Office; and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Office of Investigations Miami Office.

Alba Serrano, 66, of Miami, was sentenced today by U.S. District Judge Patricia A. Seitz in the Southern District of Florida. In addition to her prison term, Serrano was sentenced to serve three years of supervised release and ordered to pay $258,329 in restitution.

On June 6, 2012, Serrano pleaded guilty in Miami to one count of conspiracy to commit health care fraud.

According to court documents, Serrano was the owner of Elsa’s House, an ALF that she operated for more than two decades in South Miami. Serrano pleaded guilty to sending Medicare beneficiaries who resided at Elsa’s House to both ATC and HCSN for partial hospitalization program (PHP) services, a form of intensive treatment for severe mental illness, in exchange for illegal health care kickbacks. In her plea agreement, Serrano admitted that she referred beneficiaries to both ATC and HCSN in exchange for cash kickbacks, even though she knew that some of the beneficiaries did not suffer from severe mental illness and accepting health care kickbacks was illegal.

According to the plea agreement, Serrano’s participation in the fraud resulted in at least $591,385 in fraudulent billing to the Medicare program.

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Miami Assisted Living Facility Owner Sentenced for Medicare Fraud

Most mental health clinics have suspect Medicare claims

A troubling new report on for-profit mental health centers reveals nearly all of those in Houston have problems with their Medicare claims, confirming many of the problems first reported by the Houston Chronicle nearly a year ago.

The report from the U.S. Department of Health and Human Services Office of Inspector General, found that 13 of the 16 clinics in Houston – 81 percent – had “questionable” claims submitted to Medicare. These types of clinics, known as “community mental health centers,” offer intense mental health therapy in an outpatient-setting, as an alternative to a mental health hospitalization.

After examining claims submitted to Medicare during 2009 and 2010, the agency noted several billing problems: clinics billing for services not needed, patients being sent long distances for treatment and the fact that patients were not being referred to the for-profit clinics by health care providers first.

The Houston Chronicle reported nearly a year ago how the amount of Medicare dollars flowing to two troubled sectors – private ambulances and mental health clinics – was steadily rising. The news organization’s reports detailed how able-bodied Medicare enrollees were frequently being ferried by ambulances to clinics all over the Houston area.

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Most mental health clinics have suspect Medicare claims

Fla. Assisted Living Facility Owner Sent to Prison for $1.1 Million Medicare Fraud Scheme

A Miami-area assisted living facility owner has been sentenced to 37 months in prison for her role in a more than $1.1 million Medicare fraud scheme, says the Department of Justice. Billy Denica was sentenced by U.S. District Judge Joan Lenard in Miami, Fla.; in addition to her prison term, she was sentenced to two years of supervised release and has been ordered to pay $538,875 in restitution.

The kickback scheme involved funneling patients to a fraudulent mental health provider, American Therapeutic Corporation, in exchange for illegal healthcare kickbacks. Denica, the owner of Robyll Care Assisted Living Facility, admitted she knew ATC falsely billed Medicare for partial hospitalization programs (PHP)—a form of intensive treatment for severe mental illness—based on her fraudulent referrals, court documents say.

Some of her Robyll residents would be offered gifts such as money, cigarettes, and candy in exchange for agreeing to be admitted to the hospital, so they could then be referred to ATC. Denica herself would also refer her residents to the fraudulent corporation in order to receive cash kickbacks for those who went.

The ALF owner’s participation in the fraud resulted in more than $1.1 million in fraudulent billing to the Medicare system, according to the plea agreement.

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Fla. Assisted Living Facility Owner Sent to Prison for $1.1 Million Medicare Fraud Scheme