Telemedicine at Center of Billion-Dollar Healthcare Fraud Scheme
Other recent healthcare fraud cases involved a hospital leader submitting false PHP claims, a doctor charged with 26 fraud counts, and a patient recruiter accepting illegal kickbacks.
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By - Law enforcement officials in Tennessee recently charged four individuals and seven companies involved in a $1 billion healthcare fraud scheme involving telemedicine services, according to details recently released by the Department of Justice (DoJ).
The healthcare fraud scheme involved the telemedicine company HealthRight LLC based in Pennsylvania and Florida.
The defendants Andrew Assad, Peter Bolos, Michael Palso, and Larry Everett Smith, along with their compounding pharmacies located in Florida and Texas, allegedly devised the 2015 telemedicine scheme in which HealthRight fraudulently solicited insurance coverage information and prescriptions from healthcare consumers across the nation, the Justice Department reported.
According to the indictment, the individuals and their companies then used the information for prescription pain creams and other similar items. Physicians approved the prescriptions without knowing that the defendants significantly increased the prices for the prescription drugs.
The defendants supposedly billed private insurance carriers for the marked-up prescriptions. The individuals and their companies submitted at least $931 million in fraudulent claims for reimbursement, the indictment added.
READ MORE: How Providers Can Detect, Prevent Healthcare Fraud and Abuse
The healthcare fraud scheme impacted tens of thousands of patients and over 100 physicians in the Eastern District of Tennessee and across the nation, the DoJ stated. The scheme also defrauded private health insurers like Blue Cross Blue Shield of Tennessee out of about $174 million.
If convicted, the four individuals charged in the healthcare fraud scheme could face up to 20 years in prison for the mail fraud charge, up to 10 years in prison for conspiracy, and up to three years in prison for introducing misbranded drugs into interstate commerce.
The defendants could also owe fines up to $250,000 and about three years of supervised released for each count against them.
The companies would be fined up to twice the gross loss sustained as a result of the healthcare fraud conspiracy. And the indictment seeks forfeiture of about $154 million, the DoJ reported.
HealthRight LLC and its CEO Scott Roix already pleaded guilty for their roles in the telemedicine fraud scheme. The company and its leader also pleaded guilty to conspiring to commit wire fraud in a separate fraud scheme involving telemarketing of dietary supplements, skin creams, and testosterone.
Hospital administrator convicted in $16M Medicare fraud scheme
READ MORE: Strong Compliance Programs Key to Avoiding Healthcare Fraud
A federal jury recently convicted Starsky D. Bomer of Harris County, Texas, of one count of conspiracy to pay and receive healthcare kickbacks, two counts of violating the Anti-Kickback Statute, and one count of conspiracy to commit healthcare fraud.
Bomer was the Chief Financial Officer and Chief Operating Officer of Atrium Medical Center (Atrium) and Pristine Healthcare (Pristine).
Bomer and others participated in a Medicare fraud scheme in which the hospitals submitted false and fraudulent claims to the public healthcare payer for partial hospitalization program services. A partial hospitalization program provides intensive outpatient treatment to individuals with severe mental illness.
The majority of the patients receiving services through a partial hospitalization program at Atrium and Pristine did not qualify for or were never provided with legitimate partial hospitalization services, the trial revealed.
As a result, the hospitals defrauded Medicare out of approximately $16 million through the fraudulent claims, the DoJ reported.
READ MORE: OIG Releases Healthcare Fraud Compliance Program Guidelines
Evidence also showed that Bomer and others in the hospital paid illegal brides and kickbacks to group home owners and patient recruiters to incentivize the individuals to send Medicare patients to the partial hospitalization programs at Atrium and Pristine, the Justice Department stated.
Bomer disguised the illegal brides and kickbacks as salary and transportation payments.
Physician charged in 26-count healthcare fraud case
According to a new announcement from the Justice Department, law enforcement officials in Florida recently charged Sheetal Kanar Kumar, MD, with 26 counts of healthcare fraud.
The indictment stated that Kumar, the owner and operator of Advanced Healthcare for Women in Stuart, Florida, submitted or caused the fraudulent submission of claims to Medicare, Medicaid, and private payers.
Kumar, who is also a licensed obstetrician and gynecologist, allegedly billed the public and private payers for healthcare benefits, items, and services that were never provided, the DoJ explained.
The fraudulent claims added up to nearly $927,000 in reimbursements from Medicare, Medicaid, and private payers for services not delivered as billed.
Patient recruiter in TX receives nine years in prison for home health fraud
A district judge recently sentenced a patient recruiter from Texas to 108 months in prison for her involvement in a $3.6 million Medicare fraud scheme involving home health services.
US District Judge Sim Lake of the Southern District of Texas sentenced Mercy O. Ainabe after evidence presented at her trial showed that she and her co-conspirators sold the personal information of Medicare patients to home healthcare companies for kickbacks.
The DoJ also reported that Ainabe and her colleagues used the home healthcare company Texas Tender Care to submit fraudulent claims to Medicare. The claims were for services that were either not medically necessary and/or were never provided.
Aibabe then paid beneficiaries, physicians, physical therapy companies, and other healthcare stakeholders for the paperwork, Medicare beneficiary information, and services needed to operate the healthcare fraud scheme.
She disguised the kickbacks as an hourly wage for a legitimate marketing representative position, the DoJ added.
