Top Healthcare Fraud Takedowns of 2020

December 30, 2020 - 2020 will not only go down in the history books as the year COVID-19 hit, but also as a historic year for healthcare fraud takedowns.

The Department of Justice recently reported that it has charged over 300 individuals this year for their involvement in healthcare fraud, waste, and abuse schemes that resulted in more than $6 billion in false and fraudulent claims – the largest healthcare fraud enforcement action in the department’s history.

The cases involved a variety of individuals, including over 100 licensed medical professionals and more than 20 healthcare executives. The cases also spanned the usual: schemes involving products or services never provided and providers who allegedly prescribed and billed for medically unnecessary treatments and medications, including opioids.

But 2020 also saw a host of new schemes for the Justice Department, including those involving telemedicine, which was leveraged heavily during COVID-19 to preserve access to care when the pandemic was at its height.

In fact, the largest amount of alleged fraud loss charged in connection with the Justice Department’s cases involved telemedicine.

In the following article, RevCycleIntelligence explores those healthcare fraud cases that made headlines in 2020.

Telemedicine company owners charged in $56M fraud conspiracy

In February, the Justice Department announced that owners of two telemedicine companies had been charged for allegedly devising a nationwide healthcare fraud scheme that resulted in $56 million in false and fraudulent claims to Medicare.

According to an unsealed indictment, Reinaldo Wilson and Jean Wilson, husband and wife and owners of purported telemedicine companies Advantage Choice Care LLC (ACC) and Tele Medcare LLC (Tele Medcare), were charged with paying and receiving healthcare kickbacks and bribes in exchange for the ordering of orthotic braces for Medicare beneficiaries.

The Wilsons reportedly carried out the scheme by hiring healthcare providers to order the braces even if they were medically unnecessary, ineligible for Medicare reimbursement, or were not provided as represented.

Florida chiropractor charged with COVID-19, healthcare fraud

One chiropractor found himself in hot water this July when he was charged with fraudulently obtaining loans from key COVID-19 relief programs and using his office to submit false and fraudulent claims for reimbursement from Medicare and CareCredit.

The Justice Department stated that Dennis Nobbe of Miami, Florida supposedly orchestrated a scheme to exploit patients through a credit card program designed to help them pay out-of-pocket expenses for medical care. Nobbe also allegedly paid bribes to other physicians to open credit card merchant accounts in their own names.

Nobbe charged the credit cards for services he never, or only partially, provided, according to the complaint.

Furthermore, Nobbe allegedly obtained over $200,000 in Paycheck Protection Program and Economic Injury Disaster Loan (EIDL) loans intended to provide COVID-19 relief and transferred portions of the proceeds to shell companies under his control and to pay personal expenses.

Feds charge 10 individuals in $1.4B rural hospital billing scheme

One of the largest healthcare fraud takedowns in 2020 involved charges against 10 individuals, including hospital managers, laboratory owners, billers, and recruiters, for their alleged involvement in a pass-through billing scheme using struggling rural hospitals in the South.

According to the indictment announced in June, the conspirators billed private payers approximately $1.4 billion for laboratory testing claims, out of which they were paid about $400 million.

The scheme allegedly involved the takeover of small, rural hospitals that were often experiencing financial hardships and using them as a means to bill private payers for expensive urinalysis drug and blood tests that were largely performed at outside laboratories despite claims stating they were done in-house.

The conspirators also reportedly negotiated higher reimbursement rates for tests done within the rural hospitals versus outside laboratories.

All defendants have been charged with conspiracy to commit healthcare fraud and wire fraud.

$681M substance abuse treatment fraud case in Florida

The Justice Department announced in July charges in a years-long healthcare scheme involving substance abuse treatment in Palm Beach County, Florida.

The department stated that Michael J. Ligotti, DO, was charged with conspiracy to commit healthcare fraud and wire fraud after allegedly engaging in fraudulent billing for tests and treatments involving patients seeking drug and/or alcohol addiction help.

According to the criminal complaint, Ligotti authorized “standing orders” for hundreds of millions of dollars in medically unnecessary urinalysis tests as the owner of Whole Health in Delray Beach, Florida. Ligotti also reportedly paid kickbacks to sober homes or addiction treatment facilities in exchange for having their patients treated by Whole Health providers.

The scheme resulted in $681 million in fraudulent laboratory testing claims. Some patients were also billed between $10,000 and $20,000 by Ligotti and Whole Health for a single day’s visit, the Justice Department stated.

Texas doctor found guilty in $325M healthcare fraud scheme

In January, a federal jury found a Texas rheumatologist guilty of falsely diagnosing patients with life-long diseases – and treating them with medically unnecessary and toxic medications – as part of a $325 million healthcare fraud scheme.

Jorge Zamora-Quezada, MD, was convicted of one count of conspiracy to commit healthcare fraud, seven counts of healthcare fraud, and one count of conspiracy to obstruct justice after diagnosing many patients with rheumatoid arthritis and treating them for it, oftentimes with toxic medications, like chemotherapy drugs.

Patients were as young as 13 years, the Justice Department reported.

Zamora-Quezada operated medical practices throughout South Texas and San Antonio. He supposedly traveled to his various offices on his private jet and in his Maserati. 

Texas physician sentenced 84 months for healthcare fraud

In an October announcement, the Justice Department shared that a Houston, Texas-area physician and anesthesiologist at two registered pain clinics, Texas Pain Solutions and Integra Medical Clinic, received seven years in prison for his role in fraudulently billing healthcare programs.

According to the evidence, Rezik Saqer would lure vulnerable patients to the clinics by prescribing opioids, then provide unnecessary and potentially dangerous procedures and tests, many of which were performed by unlicensed staff.

Seqer fraudulently billed healthcare providers for nearly $5 million for these services, which also resulted in multiple patient deaths, the Justice Department reported.

In addition to the prison sentence, the judge also required Seqer to pay $5 million in restitution.

4 doctors found guilty in $150M healthcare fraud scheme

A federal judge found four Detroit, Michigan-area doctors guilty for participating in a Medicare fraud scheme that cost the federal healthcare program $150 million.

According to the February announcement, the doctors practiced at Tri-County Group where they would bill Medicare for medically unnecessary services, including facet joint injections, urinary drug screens, and home healthcare. Specifically, the doctors would administer the back injections in exchange for prescriptions of over 6.6 million doses of medically unnecessary opioids, the Justice Department reported.

Tri-County received higher rates for facet joint injections than any other medical clinic in the US at the time, and the four doctors all ranked in the top 25 doctors for dollars paid by Medicare for the injections despite working just a few hours a week, according law enforcement authorities.