On December 17, 2014, the U.S. Department of Justice Office of Public Affairs announced that the mastermind of a $56 million Medicare fraud scheme and his physician-accomplice have pleaded guilty in the federal court in Louisiana to conspiracy to commit health care fraud and conspiracy to falsify records in a federal investigation, and to conspiracy to commit health care fraud, respectively. Their sentencing hearings are scheduled for April 1, 2015.
According to documents filed in court, the mastermind owned many healthcare-related companies in the New Orleans area that claimed to have provided home health services and durable medical equipment (“DME”) to thousands of Medicare beneficiaries living in and around New Orleans that resulted in Medicare paying approximately $50.7 million on more than $56 million in claims submitted to Medicare by the mastermind’s companies between 2007 and 2014, the vast majority of which were fraudulent.
The mastermind was charged with paying illegal kickbacks to recruiters who canvassed New Orleans neighborhoods for Medicare beneficiary numbers, which he then used to bill Medicare for services that were not medically necessary or not provided. In a desperate attempt to hide his illegal activities, the mastermind of the massive fraud scheme (and others) allegedly fabricated tax and employment records to conceal his companies’ illegal activities in an effort to mislead the federal grand jury that had subpoenaed records from another company owned by the mastermind.
The mastermind’s physician-accomplice admitted that he signed home health referrals and wrote DME prescriptions that were used to support the fraudulent bills submitted to Medicare, in which he falsely certified that the Medicare beneficiaries were homebound and qualified for home health services, and he fraudulently wrote prescriptions for power scooters and other DME that he knew the purported beneficiaries did not need.
The federal government’s health care fraud prevention and enforcement efforts recovered $4.3 billion in taxpayer dollars in Fiscal Year (FY) 2013 from individuals and companies who attempted to defraud federal health programs serving seniors or who sought payments from taxpayers to which they were not entitled (in FY 2012, the amount was $4.2 billion; over the last five years, enforcement efforts have recovered $19.2 billion). Since 1997, the Health Care Fraud and Abuse Control (HCFAC) Program has returned more than $25.9 billion to the Medicare Trust Funds and the U.S. Treasury. For every dollar spent on healthcare-related fraud and abuse investigations in the last three years, the federal government recovered $8.10 (which was the highest three-year average return-on-investment in the 17-year history of the HCFAC Program).
In FY 2013, the U.S. Department of Justice opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants, and a total of 718 defendants were convicted of health care fraud-related crimes during the year. The U.S. Department of Justice also opened 1,083 new civil health care fraud investigations in FY 2013.
If you have knowledge of Medicare fraud that has cost the federal health care programs money and you become a whistleblower, your information and efforts in assisting the U.S. to recover the illegal payments may entitle you to monetary compensation.
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