Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

January 30: The Week That Was in Healthcare Fraud and Legality

By Ryan Mcaskill

A recap of high-profile charges, convictions and sentencing involving healthcare fraud ending the week of January 30, 2015.

- The United Stated Department of Justice has put a stop to a number of different high-value healthcare scams and charged, convicted or sentences several physicians, executives and companies. The charges resulted in multiple millions of dollars in fraud and months or years in jail.

Here is a roundup of some of the legal dealings from the past week.

COO sentenced to six years for $67 Million in Medicare Fraud

Christopher Gabel, the former COO of the Hollywood Pavilion psychiatric hospital was sentenced to six years in federal prison and order to repay $39.3 million for running a Medicare scheme that falsely claimed $67 million from Medicare. $40 million was paid out.

It was determined that between April 2003 and September 2012, the provider found Medicare beneficiaries across the country through patient brokers and paid kickbacks to acquire them. They then billed for services not provided or that were not medically necessary.

Gabel is the fifth executive to be sentenced in this case. The others, convicted in June 2013, are service at least 12 years in prison and are asked to pay between $20 and $40 million in restitution.

Four sentenced in $6 Million home health scheme

This week, four South Florida residence were sentenced for their role in an extensive, $6.2 million Medicare fraud scheme. It was run out of Professional Medical Home Health, a Miami based agency that provided home health and therapy services. They are also believed to be connected with similar schemes.

All four pled guilty back in November of 2014. Dennis Hernandez, was sentenced to 120 months in prison and ordered to pay $1,438,186 in restitution.  Jose Alvarez, was sentenced to 120 months in prison and ordered to pay $2,972,570 in restitution.  Joel San Pedro, was sentenced to 97 months in prison and ordered to pay $4,938,432 in restitution.  Alina Hernandez was sentenced to 24 months in prison and ordered to pay $204,526.05 in restitution.

The group admitted that the company was operated for the purpose of billing Medicare programs for expensive services like physical therapy and home health that were either not medically necessary or provided at all. They also acted as patient recruiters and provided kickbacks to recruit beneficiaries.

Psychotherapist charges $500,000 to dead patients

A psychotherapist and and his employee have been charged with faking Medicare claims and billing for treatment on patients that are dead. According to the Chicago Sun Times, Jonathan Levy and Janice Nakao submitted false claims for nearly $500,000.

Aside from claiming dead patients, the pair also billed for services it never provided, sent unqualified workers to nursing homes and charged as if Levy had preformed the services and provided group sessions, but billed them as individual ones, which has a higher reimbursement rate.

 

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