{"id":9269,"date":"2016-08-21T00:01:23","date_gmt":"2016-08-21T00:01:23","guid":{"rendered":"https:\/\/www.edrugstore.com\/blog\/?p=9269"},"modified":"2016-08-30T18:52:05","modified_gmt":"2016-08-30T18:52:05","slug":"feds-bust-up-1-billion-medicare-scam-in-south-florida","status":"publish","type":"post","link":"https:\/\/www.edrugstore.com\/blog\/current-health-news\/feds-bust-up-1-billion-medicare-scam-in-south-florida\/","title":{"rendered":"Feds Bust Up $1 Billion Medicare Scam in South Florida"},"content":{"rendered":"
\"Medicare\"
In the South Florida scheme, an estimated 14,000 elderly patients were placed in nursing homes and assisted living centers although they did not meet the criteria for such placements.<\/figcaption><\/figure>\n

Federal law enforcement authorities in late July 2016 broke up what has been described as the biggest individual Medicare fraud scheme in history.<\/p>\n

Indicted was the owner-operator of a chain of skilled nursing\/assisted living homes, who together with two alleged co-conspirators was charged with bilking Medicare out of more than $1 billion by filing claims for services that were either unnecessary or never really provided.<\/p>\n

According to the case brought by the U.S. Department of Justice<\/a>, 47-year-old Philip Esformes, owner of more than 30 Miami area nursing homes and assisted living facilities, led “a complex and profitable health care fraud scheme that resulted in staggering losses.” Indicted along with Esformes were 49-year-old hospital administrator Odette Barcha and 56-year-old physician assistant Arnaldo Carmouze.<\/p>\n

Large-Scale Operation<\/b><\/p>\n

According to findings from a Justice Department investigation, Esformes placed roughly 14,000 elderly individuals in nursing homes and assisted living facilities even though they did not meet the criteria for placement in these facilities. According to a DOJ press release outlining the government case against Esformes and his co-conspirators, the three were indicted on charges of health care fraud, conspiracy, and money laundering.<\/p>\n

Esformes and Barcha, former outreach director at Larkin Community Hospital in South Miami, were also charged with obstruction of justice, according to the indictments. Specifically, Esformes was charged in connection with the case of Miami brothers Guillermo and Gabriel Delgado, who allegedly sold the names of Medicare patients to an unscrupulous pharmacist. Following their 2014 arrests, Esformes allegedly sought to finance Guillermo Delgado’s flight from the United State to avoid trial.<\/p>\n

\"Medicare\"
It’s estimated that Medicare fraud costs U.S. taxpayers roughly $60 billion a year.<\/figcaption><\/figure> Phony Contracts Allegedly Created<\/b><\/p>\n

Barcha was charged with obstruction of justice because she allegedly created phony medical director contracts shortly after she received a grand jury subpoena in June 2016. The sham contracts reportedly were designed to disguise and conceal the payment of kickbacks she made in return for patient referrals for admission to nursing homes and assisted living care centers owned and operated by Esformes.<\/p>\n

The indictments of Esformes, Barcha, and Carmouze were announced in Miami at a press conference on July 22, 2016. Appearing on behalf of the Justice Department were Assistant Attorney General Leslie R. Caldwell of the department’s Criminal Division and U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida. Appearing with them were Special Agent in Charge George L. Piro of the FBI’s Miami Field Office and Special Agent in Charge Shimon R. Richmond of the U.S. Department of Health and Human Services-Office of Inspector General.<\/p>\n

Kickbacks Collected as Well<\/b><\/p>\n

On top of the profits he reaped by steering thousands of elderly patients into his network of nursing homes and assisted living facilities, Esformes and his alleged co-conspirators further enriched themselves by sending many of these elderly patients to other Miami-area health care providers, for which the co-conspirators received kickbacks. According to the indictments, those health care providers, including home health care providers and community mental health centers, also provided medically unnecessary services that were then billed to Medicare or Medicaid.<\/p>\n

Marissel Descalzo and Michael Pasano, defense attorneys representing Esformes, told the Miami Herald<\/a> that their client had committed no wrongdoing. In a statement released on Esformes’ behalf, they said that the government’s charges against their client “appear to come from people who were caught breaking the law and are now hoping to gain reduced sentences. Mr. Esformes adamantly denies these allegations and will fight hard to clear his name.”<\/p>\n

Esformes Involved in Earlier Case<\/b><\/p>\n

The 2016 indictments against Esformes are not the first time he’s been charged with health care fraud, according to government investigators. They cite court documents showing that Esformes paid $15.4 million to resolve civil charges of similar misconduct in 2006. In that case, Esformes allegedly admitted patients from assisted living facilities into a Miami-area hospital. With that civil case in his rear-view mirror, Esformes and his co-conspirators employed more sophisticated money laundering techniques to hide their fraudulent dealings from investigators.<\/p>\n

The Justice Department press release issued in connection with the indictments of Esformes, Barcha, and Carmouze credits “advanced data analysis and forensic accounting techniques” with helping them to break the case.<\/p>\n

Fraud Said to Be Pervasive<\/b><\/p>\n

Pointing out that Medicare fraud has infected “every facet” of America’s health care system, Ferrer said that the government’s “unrelenting efforts” to combat fraud “continue to identify and prosecute the criminals who, driven by greed, steal from a program meant for our aged and infirmed to increase their personal wealth.” Caldwell said the indictments offer proof that “data-driven law enforcement” has been a successful tool in tracking down health care fraud.<\/p>\n

Although this case is far larger than the average Medicare fraud scheme, it is emblematic of criminal wrongdoing that collectively costs American taxpayers billions of dollars each year. In a 2014 article, The New York Times<\/a> said that Medicare fraud and systematic overcharging amount to an estimated $60 billion every year. That figure is roughly equivalent to 10 percent of Medicare’s annual spending. Tracking down fraud is a daunting challenge, given that the Centers for Medicare and Medicaid Services manually reviews only about 3 million of the 1.2 billion claims it receives each year. That amounts to only one-quarter of 1 percent. According to the New York Times article, the government only recovers a small portion of the money lost each year to Medicare fraud. In 2013, the government reportedly recovered $4.3 billion, only about 7 percent of the $60 billion estimated to be lost annually to Medicare fraud.<\/p>\n

\"Medicare\"
Medicare fraud is committed by people in all walks of life, including some unscrupulous health care providers.<\/figcaption><\/figure> Smaller Cases Often Go Unnoticed<\/b><\/p>\n

While the recent Miami indictments got headlines in newspapers around the country, Medicare health care fraud on a less spectacular scale is ongoing. And experts estimate that only a portion of that fraud is ever detected.<\/p>\n

Helping the government to track down more cases of health care fraud is the Medicare Fraud Strike Force, which only a month before the Miami indictments led a nationwide sweep that uncovered about $900 million in false billings. Announced jointly by Attorney General Loretta Lynch and HHS Secretary Sylvia Matthews Burrell, that sweep resulted in criminal and civil charges against 301 individuals, including 61 doctors, nurses, and other licensed medical professionals. The sweep by the Medicare Fraud Strike Force covered 36 federal districts. Assisting the strike force in this investigation of widespread health care fraud were 23 state Medicaid Fraud Control Units.<\/p>\n

Expanded Strike Force<\/b><\/p>\n

In a July 28, 2016, editorial<\/a>, The New York Times recognized the role the strike force has played in tracking down Medicare fraud, citing the June and July arrests that together uncovered almost $2 billion in fraudulent billings. It also recognized the role that Obamacare has played in strengthening the investigatory powers of the strike force. According to the editorial, the Affordable Care Act of 2010 provided an additional $350 million to expand the strike force “to nine cities, from only two in 2007, and to develop advanced data and accounting systems to uncover fraud.”<\/p>\n

If you would like to read additional articles on topics of interest to health consumers, check out our blog<\/a>.<\/p>\n

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Federal law enforcement authorities in late July 2016 broke up what has been described as the biggest individual Medicare fraud scheme in history. Indicted was the owner-operator of a chain of skilled nursing\/assisted living homes, who together with two alleged co-conspirators was charged with bilking Medicare out of more than $1 billion by filing claims […]<\/p>\n","protected":false},"author":1,"featured_media":9316,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_autoblog_aioseo_focus_keyphrase":"","_autoblog_aioseo_title":"","_autoblog_aioseo_description":"","footnotes":""},"categories":[18],"tags":[],"class_list":["post-9269","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-current-health-news"],"acf":[],"aioseo_notices":[],"aioseo_head":"\n\t\t\n\t\n\t\n\t\n\t\n\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t