Category: Uncategorized

MM Curator summary:

Peter Khaim and Arkadiy Khaimov (NYC) stole $30M from Medicaid using billing override codes during the COVID pandemic. Got paid for cancer med Targretin Gel – that was never provided or even authorized by a doctor.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Clipped from: https://dailyvoice.com/new-jersey/fortlee/news/covid-19-feds-charge-nyc-area-pharmacy-owners-in-30-million-health-care-fraud/800165/

Agents with U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) Photo Credit: COURTESY: HHS-OIG

The owners of more than a dozen New York City-area pharmacies exploited the COVID-19 pandemic to scam Medicaid out of $30 million, then used the money to buy themselves real estate and luxury items, federal authorities charged.

Peter Khaim, 40, and Arkadiy Khaimov, 37, both of Forest Hills, got others to pose as pharmacy owners or supervisors to take advantage of emergency override codes added to the Medicare system during the national state of emergency, an indictment returned by a grand jury in Brooklyn alleges.

They used these to submit fraudulent claims for the expensive cancer medication Targretin Gel 1%, none of which was ever provided, ordered, or even authorized by medical professionals, it says.

Targretin Gel 1% has an average wholesale price of roughly $34,000 for each 60-gram tube, federal authorities noted.

The drugs were often ordered during periods when pharmacies weren’t operating, using doctors’ names on prescriptions without their permission, they said Monday.

Khaim and Khaimov paid others to pose as the owners of the pharmacies and hired pharmacists to pretend to be supervisors “for the purpose of obtaining pharmacy licenses and insurance plan credentialing,” Acting Assistant Attorney General Brian C. Rabbitt of the Justice Department’s Criminal Division said.

To launder the money, the pair “created sham pharmacy wholesale companies, which they named after pre-existing pharmacy wholesalers,” Rabbitt said.

They also “fabricated invoices to make it appear that funds transferred from the pharmacies to the sham pharmacy wholesale companies were for legitimate pharmaceutical drug purchases,” he added.

The pair conspired with an international money launderer who arranged for funds to be wired from the sham pharmacy wholesale companies to companies in China for distribution to individuals in Uzbekistan, federal authorities said.

Members of the Uzbekistani immigrant community funneled back through an unlicensed money transfer business, minus a commission that was deducted by the money launderer, they said.

When the amount of fraudulent proceeds exceeded the amount of cash available in the Uzbekistani immigrant community, Rabbitt said, Khaim and Khaimov “directed the international money launderer to transfer funds back from the sham wholesale companies to the defendants, their relatives, or their designees, in the form of certified cashier’s checks and bags of cash that were dropped at their house in the middle of the night.

“The defendants used the proceeds of the scheme to purchase real estate and other luxury items,” he said.

Khaim and Khaimov are each charged with conspiracy to commit health care fraud and wire fraud and conspiracy to commit money laundering.

Khaim also was separately charged with concealing money laundering and aggravated identity theft.

Khaimov also was separately charged with concealing money laundering.

Both men “lined their own pockets by exploiting Medicare flexibilities that were designed to ensure that patients obtained access to needed medications during the COVID-19 crisis,” Rabbitt said.

“The changes to this program, funded by taxpayers, were put in place to help fellow citizens obtain needed medications during the pandemic, not line the pockets of fraudsters,” said Acting Director in Charge William F. Sweeney Jr. of the FBI’s New York Field Office.

“Those who attempt to illegally profit from our public funded healthcare programs should remember taxpayers also fund courts and jails,” Sweeney said.

The U.S. Department of Health and Human Services Office of Inspector General’s New York Field Office investigated the case along with the IRS-Criminal Investigation’s New York Field Office and the Federal Deposit Insurance Corporation’s Office of Inspector General.

Assistant Chief Jacob Foster of the Criminal Division’s Fraud Section’s National Rapid Response Strike Force and Trial Attorney Andrew Estes and Assistant Chief Brendan Stewart of the Fraud Section’s Brooklyn Strike Force are prosecuting the case.  

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MM Curator summary:

MA homecare company (Maestro) stole $10M from Medicaid billing for services that had not been authorized by a physician.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

MAURA HEALEY

BOSTON — In ongoing efforts to combat fraud in the home health industry, Attorney General Maura Healey announced Friday that her office reached a $10 million settlement with a Lawrence-based home health care company and its owner to resolve allegations that they falsely billed the state’s Medicaid Program (MassHealth) for unauthorized services. The company, Maestro-Connections Health Systems, LLC, has an office in Athol.

Pursuant to a settlement agreement with the AG’s Office, Maestro and CEO George Kiongera will pay $10 million to resolve allegations that, from January 2014 through August 2019, they knowingly submitted false claims to MassHealth and MassHealth managed care entities for home health services that had not been appropriately authorized by a physician. Maestro has locations in Lawrence, Auburn, Athol, Framingham, Taunton, Holyoke, and Lynn.

“Companies like Maestro that defraud MassHealth take vital resources away from the program and the people who need them most,” said AG Healey. “Since 2016, my office has recovered $40 million for MassHealth by combating fraud, waste, and abuse in the home health industry. Our work continues to ensure health care dollars are spent appropriately.”

“MassHealth identified allegations of fraudulent billing by Maestro and referred the company to the Attorney General’s Medicaid Fraud Division,” said Assistant Secretary and Medicaid Director Dan Tsai. “Today’s outcome demonstrates the ongoing work between MassHealth and the Medicaid Fraud Division and MassHealth’s program integrity efforts to prevent inappropriate payments.”

“The submission of false claims to the MassHealth program drains resources from legitimate patient care,” said Phillip M. Coyne, Special Agent in Charge, Office of the Inspector General of the U.S. Department of Health and Human Service’s Boston Regional Office. “I appreciate the partnership with the Medicaid Fraud Division of the Massachusetts Attorney General’s Office in holding accountable those that seek to exploit this vital taxpayer-funded program.”

To bill MassHealth for home health services, a provider must ensure that the member’s physician has reviewed and signed a plan of care certifying that home health services are medically necessary. Home health agencies are required to maintain these records for at least six years after the medical services are provided and claims have been presented for payment. The AG’s Office alleges that Maestro billed for services for which it did not have valid, signed plans of care certifying that those services were medically necessary.

In addition to the financial payment, the settlement also includes a requirement that Maestro not resume providing services to MassHealth members until it has hired an independent compliance monitor to oversee a three-year compliance program. That program will include updated policies and procedures, new training for staff, and yearly audits conducted by the monitor.

In a November 2017 settlement with the AG’s Fair Labor Division, Maestro and Kiongera agreed to pay more than $1 million in restitution and penalties after failing to pay overtime to more than 600 home health aides and failing to keep accurate payroll records.

Today’s settlement is part of a larger effort by AG Healey and MassHealth to combat fraud in the home health industry.

Clipped from: https://www.atholdailynews.com/AG-Healey-combats-fraud-in-home-health-industry-37898036

MM Curator summary:

Steven Yohay of Brooklyn paid homeless New Yorkers to admit into his rehab facilities, stealing $3M from NY Medicaid.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Bribed homeless people to enroll, used forged evaluations

New York Attorney General Letitia James on Monday announced an agreement with A.R.E.B.A.-CASRIEL, Inc. d/b/a/ Addiction Care Interventions Chemical Dependency Treatment (ACI) and its majority owner, Steven Yohay, regarding multiple schemes that defrauded the state Medicaid program, as part of a joint state-federal investigation. 

Filed this past Friday in the United States District Court for the Southern District of New York, ACI and Yohay admitted that they failed to respond to reports of wrongdoing — which the investigation substantiated — that ACI engaged in multiple illegal schemes, including that its employees bribed homeless people into getting inpatient treatment there.

ACI admitted to many instances of  fraudulent behavior, such as: paying an individual for a “no-show” job at ACI, while that person worked as a full-time employee at another organization with the same function as ACI; encouraging “outreach” drivers who regularly bribed potential Medicaid patients into seeking inpatient treatment at ACI, many of whom were experiencing homelessness at the time; and allowing Medicaid patients to enroll in its inpatient treatment program despite not being evaluated by a qualified health care professional. 

Instead of the evaluations, ACI used fraudulent signatures from medical providers that were photocopied onto medical forms in order to falsely substantiate an evaluation by a medical provider where none had occurred, the New York State AG’s Office said. 

Among these allegations, the most serious incidents took place between January 2014 and December 2019, when ACI’s “outreach” drivers coerced out-of-state residents to enroll in ACI’s inpatient treatment program by offering them money, drugs and/or alcohol. 

“Exploiting individuals who are experiencing homelessness is disgraceful,” said Attorney General James. “My office will use its power to seek out Medicaid providers looking to defraud the Medicaid system and New York state taxpayers.”

ACI has agreed to reimburse the New York state Medicaid program in the amount of $3 million, and Yohay personally agreed to reimburse the New York state Medicaid program another $3 million. 

Additionally, all current owners of ACI, including Yohay’s brother, agreed to divest themselves of their ownership interests in ACI. Yohay has also agreed to be banned from participation as a provider in any government-funded health care program for fifteen years. 

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The new owners of ACI have agreed to be bound by the terms of this agreement, which includes changes to the ACI program to ensure it steers clear of future illegal conduct. 

The case against ACI and Yohay was initiated by a former employee and whistleblower, who will receive a portion of the agreement. The whistleblower lawsuit was filed under the qui tam provisions of the federal and New York State False Claims Act, which allows average citizens to file civil actions on behalf of the government and to share in the proceeds of any recovered funds.

New York’s claims in the qui tam case were handled by the Medicaid Fraud Control Unit (MFCU) in the Office of the Attorney General (OAG), which worked closely with the U.S. Attorney’s Office for the Southern District of New York.

This case is being prosecuted by Special Assistant Attorneys General David G. Abrams and Amy B. Delfyett, with assistance from Civil Enforcement Chief Alee N. Scott and NYC Regional Director Christopher M. Shaw. 

The Medicaid Fraud Control Unit of the Office of the New York State Attorney General enforces laws that protect the public by addressing Medicaid provider fraud and that protect nursing home residents from abuse and neglect.

If someone believes they have information about Medicaid provider fraud or about an incident of abuse or neglect of a nursing home resident, they can file a confidential complaint online on the OAG website at https://ag.ny.gov/nursinghomes or by calling the MFCU hotline at 212-417-5397. 

Clipped from: https://brooklyneagle.com/articles/2020/12/22/drug-clinic-admits-phony-billing-scheme-agrees-to-pay-nys-6-million/

MM Curator summary:

Trump pardoned the Miami fraudster behind a $1.3B Medicare and Medicaid fraud scheme.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Clipped from: https://www.chicagotribune.com/news/criminal-justice/ct-philip-esformes-fraud-trump-clemency-commutation-20201223-tfn7rveawzdhjmhee6hx7eoccm-story.html

In this Aug. 7, 2015, file photo, Philip Esformes arrives at the 15th Annual Harold and Carole Pump Foundation Gala held at the Hyatt Regency Century Plaza, in Los Angeles. (Rob Latour/Invision/AP)

Chicago-area nursing home mogul Philip Esformes was once called the “king” of Medicaid fraud, accused of cycling elderly, destitute and drug-addicted patients through his network of facilities and billing millions of dollars to government programs, often for services never rendered, according to federal prosecutors.

In sentencing Esformes to 20 years in prison last year, a federal judge in Miami called the length and scope of his criminal conduct “unmatched in our community, if not the country” and an “epic” violation of trust.

Now, Esformes, 52, is a free man, released from a Florida prison on Tuesday after President Donald Trump commuted his sentence, granting clemency to 20 people in all. The group included former Republican members of Congress; military contractors convicted of killing civilians in Iraq; and Chicagoan George Papadopoulos, a campaign aide who pleaded guilty to making false statements in the investigation into Russian interference in the 2016 election.

Esformes was arrested in 2016 at his Miami estate and charged with a massive $1.3 billion Medicare and Medicaid fraud scheme that at the time was billed by the U.S. Justice Department as the largest single criminal health care fraud case ever brought.

In announcing the president’s decision, the White House said the clemency was supported by former Attorneys General Edwin Meese and Michael Mukasey, as well as former Deputy Attorney General Larry Thompson.

A statement by press secretary Kayleigh McEnany alluded to Esformes’ pending appeal of his conviction, which alleged massive overreach by overzealous prosecutors who used illegally gathered evidence at trial that violated the attorney-client privilege. The statement also noted that Esformes “has been devoted to prayer and repentance” while in prison and is in declining health.

His attorney, Howard Srebnick, did not comment directly on the president’s order, but said in a statement that the comments from the White House demonstrate “that the president was deeply disturbed by the prosecutors’ invasion of the attorney-client privilege.”

The Chicago Tribune began chronicling Esformes’ rise to nursing home mogul more than a decade ago, when he, along with his father and business partner controlled a network of more than two dozen health care facilities that stretched from Chicago to Miami.

At one point, the flashy, Ferrari-driving Esformes owned millions of dollars in real estate, crisscrossing the country on private jets to spend time at his luxury condominium on Chicago’s Magnificent Mile and mansions in Miami and Los Angeles.

But allegations of fraud and neglect piled up in Chicago and Miami. A 2010 whistleblower lawsuit alleged that the giant pharmaceutical firm Omnicare Inc. paid millions in kickbacks to secure long-term contracts with Esformes’ facilities, the Tribune reported.

The Tribune also found that families had filed 20 wrongful death lawsuits over a four-year period against seven of Esformes’ facilities in Miami-Dade County, including one case where a patient was allegedly attacked by a fellow resident, then sent to another Esformes-owned facility, where he suffered a catastrophic fall and died of a brain injury.

His indictment alleged Esformes and a handful of Miami co-conspirators bilked the federal programs for 14 years by cycling some 14,000 patients through various facilities, where many received unnecessary or even harmful treatments. Drug addicts were allegedly lured to the facilities with promises of narcotics, and prosecutors say some received OxyContin and fentanyl without a physician’s order to entice them to stay.

He housed elderly patients alongside younger adults who suffered from mental illness and drug addiction — sometimes with fatal results, prosecutors alleged. In Esformes’ Oceanside Extended Care Center in Miami Beach, “an elderly patient was attacked and beaten to death by a younger mental health patient who never should have been at (a nursing facility) in the first place,” prosecutors wrote in a pre-sentencing memorandum.

As part of the kickbacks exchanged between Esformes and corrupt medical professionals, “high-end escorts” were flown to Orlando and chauffeured in limousines for liaisons with Esformes at the Ritz-Carlton Hotel, according to prosecutors.

Esformes, meanwhile, drove a $1.6 million Ferrari Aperta and published a blog with fitness tips for busy executives, prosecutors said. He even used some $300,000 in stolen proceeds to bribe the head men’s basketball coach at the University of Pennsylvania to admit Esformes’ son to the school, according to one count of the indictment.

That coach, Jerome Allen, pleaded guilty to money laundering and testified against Esformes at the Miami trial.

A jury convicted Esformes of paying bribes, money laundering, and other crimes, but was unable to reach a verdict on the main count of conspiring to defraud the Medicare program for the elderly and indigent. His appeal is pending before the 11th Circuit U.S. Court of Appeals in Florida, records show.

At his sentencing hearing in January 2019, Esformes wept and pleaded for mercy, saying “there is no one to blame but myself.” While preparing his defense, Esformes told the judge, he had listened repeatedly to wiretapped conversations that revealed him arranging bribes and was “disgusted” by what he heard.

“The Phil Esformes you heard was reckless … an arrogant man,” he said, crying as he pounded the lectern with his fist.

Prosecutors had requested 30 years behind bars. But U.S. District Judge Robert Scola Jr. said he was taking into account Esformes’ history of helping people in need.

Attorneys for Esformes had described him as a selfless philanthropist who had donated more than $15 million to synagogues, schools and needy individuals, often anonymously.

jmeisner@chicagotribune.com

MM Curator summary:

Rebecca Fruge fraudulently billed $76,000 for in home medical services for times her client was in the hospital, and for 3 different 24 hour days.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

BISMARCK, N.D. (AP) — The North Dakota attorney general’s office is charging a Mandan woman with Medicaid fraud for allegedly submitting $76,000 worth of claims for work she did not perform.

The Bismark Tribune reports the Department of Human Services began looking into claims Rebecca Fruge made for in-home medical services after she claimed she had performed more than 24 hours of work on three separate days in May last year.

The department also found that Fruge’s client was in the hospital for one of those days and could not have received services from her. Fruge has denied submitting incorrect or fraudulent claims, investigators say.

Clipped from: https://www.kxnet.com/news/local-news/north-dakota-ag-charges-service-provider-with-medicaid-fraud/

MM Curator summary:

A Kentucky dentist plead guilty to stealing $70,000 from Medicaid in an upcoding scheme.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

By Bill Estep

December 17, 2020 09:27 AM

An Eastern Kentucky dentist who admitted getting higher payments from Medicaid through inflated bills has been sentenced to four months in prison.

Denver “Dickie” Tackett also must serve six months of home detention after his prison sentence, repay $70,012 to Medicaid and pay the government $20,000.

U.S. District Judge Gregory F. Van Tatenhove sentenced Tackett on Tuesday.

Tackett, who practiced for more than 30 years at McDowell, in Floyd County, pleaded guilty in August to a charge of health care fraud.

Tackett acknowledged that he submitted claims for treating patients that were not reasonable and necessary between 2003 and 2018.

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One example was that he filed claims to be paid for performing more complex surgical tooth extractions when he had only done simple extractions, which were reimbursed at a lower rate, according to the plea agreement.

Tackett billed Medicaid for some medically unnecessary procedures; submitted claims for providing emergency care without sufficient justification; and filed claims to get paid for procedures related to an earlier unnecessary extraction, the plea agreement said.

Tackett acknowledged pulling people’s teeth when it wasn’t necessary, but his attorney, Andrew L. Sparks, said patients asked Tackett to do that.

It was not uncommon for people to ask to have their teeth pulled while the service was covered by Medicaid out of concern that they would lose coverage later, Sparks said in a sentencing memorandum.

The indictment in the case also charged Tackett with 15 counts of improperly distributing opioid pain pills, but those charges were dropped as part of the plea.

Sparks sought probation for Tackett, noting letters of support that described Tackett as a caring, dedicated dentist who worked long hours to help people, treated patients even if they couldn’t pay and sometimes paid for a patient’s prescription.

One woman described how her son damaged a front tooth playing basketball and Tackett opened his office at 7 p.m. on Christmas Eve to treat him, saving the tooth.

Tackett, who is an ordained minister through the United Methodist Church and the Assembly of God Pentecostal Church, was not motivated by a desire for wealth, according to the sentencing memo.

“Dr. Tackett’s history and characteristics show a man dedicated to his faith, his family and his patients,” the memo said. “These letters make clear that Denver Tackett is a good and decent man.”

Sparks argued Tackett had been punished enough by losing his practice.

Prosecutors argued for a sentence of 18 to 24 months, saying the health care system depends on providers being trustworthy and assumes that they will only bill for necessary services they actually perform.

A review by a consultant at the University of Kentucky showed a pattern by Tackett of prolonging treatment and performing procedures patients didn’t need, resulting in payments to him, prosecutors said.

Prosecutors also argued that prescriptions Tackett wrote for opioid painkillers played a role in the drug problem.

“Several of these patients told investigators that they became addicts as a result of Dr. Tackett’s prescriptions or that Dr. Tackett contributed to their addictions by continuing to prescribe controlled substances to them,” prosecutors wrote.

Tackett was among 60 health providers in seven states charged in April 2019 as part of an investigation of alleged improper prescribing.

Some other providers charged in Kentucky in the roundup have also been convicted.

Clipped from: https://www.kentucky.com/news/local/crime/article247913615.html

MM Curator summary:

A surgeon and his office manager billed Medicare and Medicaid for more than 3,000 surgeries that never happened. In the process they stole $23M.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Kimberly Austin changed her plea in a hearing on the afternoon of Nov. 13.(WCTV)

TALLAHASSEE, Fla. (WCTV) – The office manager of Dr. Moses deGraft-Johnson plead guilty to one count of conspiracy to commit healthcare fraud on Friday. Kimberly Austin changed her plea in a hearing on the afternoon of Nov. 13.

Austin and deGraft-Johnson were indicted in February; the 58 count indictment alleges that they defrauded Medicare and Medicaid, billing for surgeries that were never performed. Prosecutors say the improper billing hit $23 million; they said in 3,600 surgeries billed over five years, 85 to 90% never happened.

Prosecutors also say the surgery deGraft-Johnson claimed to perform is “relatively rare,” and that he did not have enough of the devices required to do the surgeries.

The two worked at the Heart and Vascular Institute of North Florida.

The change of plea hearing for Austin lasted about 45 minutes, with the Judge checking that her guilty plea was not coerced and ensuring it is “voluntary and factual.”

Austin faces up to 10 years in prison for the conspiracy charge.

During her testimony, she said she was born, raised, and has always lived in Sneads, Florida.

She was visibly shaken during the testimony in front of Judge Mark Walker.

“It’s readily apparent to me that you’re upset, that you’re remorseful,” said Judge Walker. “I can tell this is a big deal to you.”

The Judge went over three documents during the hearing: a plea agreement, a supplemental plea agreement, and a statement of facts. He explained that it is up to the prosecutors to file a substantial assistance motion, depending on her testimony.

The statement of facts was 59 pages; Judge Walker cross-checked certain aspects with Austin.

“He used your assistance to pull of his scheme, correct?” he asked.

“Yes, sir,” said Austin.

“You admit you helped him commit healthcare fraud?”

“Yes, sir,” said Austin.

Austin testified that she covered for the doctor when patients called and complained, and said she knew he was billing for procedures that took place when he was out of the office.

She is out of custody under the conditions previously set by the magistrate judge. Austin’s sentencing is set for 2:30 p.m. on March 18; deGraft-Johnson’s trial is set for Jan. 25.

Clipped from: https://www.wctv.tv/2020/12/14/office-manager-of-doctor-indicted-for-23-million-in-healthcare-fraud-pleads-guilty/