MM Curator summary
[MM Curator Summary]: A complex scheme that paid telemarketers to cold call members and docs to authorize scripts stole at least $30M.
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.
This week, a federal judge in Greeneville, Tennessee, sentenced seven individuals and seven related corporate entities for their roles in a multimillion-dollar health care fraud scheme.
According to court documents and evidence presented at trial, Peter Bolos and his co-conspirators, Michael Palso, Andrew Assad, Scott Roix, Larry Smith, Mihir Taneja, Arun Kapoor and Maikel Bolos, as well as various companies owned or controlled by some of these individuals, deceived pharmacy benefit managers (PBMs), such as Express Scripts and CVS Caremark, regarding tens of thousands of prescriptions. The PBMs processed and approved claims for prescription drugs on behalf of insurance companies. Bolos and his co-conspirators defrauded the PBMs into authorizing millions of dollars’ worth of claims that private insurers such as Blue Cross Blue Shield of Tennessee, and public insurers such as Medicaid and TRICARE, paid to pharmacies controlled by the co-conspirators.
Peter Bolos was convicted by a federal jury in December 2021. Roix, Assad, Palso, Smith, Maikel Bolos, and various associated business entities pleaded guilty to their roles in the conspiracy. Taneja, Kapoor, and Sterling Knight pleaded guilty to felony misbranding in a conspiracy with Bolos. U.S. District Judge J. Ronnie Greer imposed sentences this week for all of the defendants except Roix, whose sentencing hearing was rescheduled for June 15, 2022.
On May 16, the court sentenced Bolos to 14 years in prison and $2.5 million in forfeiture. On the same date, the court also sentenced Palso, 48, of Lutz, Florida, to 33 months in prison. Bolos and Palso also were each ordered to pay nearly $25 million in restitution.
On May 17, the court sentenced Smith, 52, of Tampa, to 42 months of imprisonment. The now-defunct corporate entities that Smith created, Alpha Omega Pharmacy, Germaine Pharmacy, Zoetic Pharmacy, ULD Wholesale LLC, and Tanith Enterprises, all were sentenced to pay nearly $25 million in restitution. The court also sentenced Taneja, 47, of Tampa, to 10 months of imprisonment and a $10,000 fine.
On May 18, the court sentenced Kapoor, 48, of Temple Terrace, Florida, to three years’ probation and a $10,000 fine. Sterling Knight, a now-defunct corporate entity that Kapoor and Taneja created, was sentenced to pay $21 million in restitution. The court also sentenced Maikel Bolos, 36, of Tampa, to 15 months of imprisonment and a $25,000 fine.
On May 19, the court sentenced Assad, 37, of Tampa, to 24 months of imprisonment and to pay nearly $25 million in restitution. HealthRight was sentenced to pay $4.25 million in restitution.
“The significant sentences imposed by the court reflect the seriousness of this large-scale fraud scheme, in which the defendants deceived consumers in order to facilitate the distribution of drugs without proper medical oversight, and overbilled insurers for illegal prescriptions,” said Deputy Assistant Attorney General Arun G. Rao, head of the Civil Division’s Consumer Protection Branch. “The department will continue to work with law enforcement partners to prosecute those who take advantage of telemedicine to perpetrate fraud schemes that violate the Food, Drug, and Cosmetic Act.”
“The scale of the prescription-drug fraud scheme orchestrated by these defendants and their conspirators was astonishing, and the court’s prison sentences reflect the seriousness of their crimes,” said U.S. Attorney Francis M. Hamilton III for the Eastern District of Tennessee. “The financial harm caused by health care fraud hurts all Americans, and the United States Attorney’s Office for the Eastern District of Tennessee will continue to support the cooperation among its federal law enforcement partners that is necessary to bring criminal swindlers like these defendants to justice.”
“This sentencing is the result of a multi-agency investigation into a complex telemedicine pharmacy fraud scheme, requiring substantial investigative resources,” said Special Agent in Charge Joseph E. Carrico of the FBI Knoxville Field Office. “The FBI, with its law enforcement partners, will remain vigilant to assure that unscrupulous individuals who exploit our health care system are brought to justice.”
“Distributing misbranded prescription drugs in the U.S. marketplace places patients’ health at risk,” said Special Agent in Charge Justin C. Fielder of the FDA Office of Criminal Investigations (OCI) Miami Field Office. “We will continue to pursue and bring to justice those who put profits ahead of public health.”
“Bolos and his co-conspirators abandoned their responsibilities in the health care industry through an elaborate fraud scheme and manipulated the system without regard for patient need or medical necessity to line their pockets,” said Special Agent in Charge John Condon of Homeland Security Investigations (HSI) Tampa. “These significant sentences should serve as a warning to anyone who attempts to deceive the government and steal from taxpayers.”
“Providers who solicit beneficiaries’ personal information and use it to defraud federal health care programs not only undermine the integrity of those programs; they also divert valuable taxpayer dollars for self-serving purposes,” said Special Agent in Charge Tamala E. Miles of the Department of Health and Human Services, Office of Inspector General (HHS-OIG). “HHS-OIG is proud to work alongside our law enforcement partners to investigate and hold accountable perpetrators of federal health care fraud.”
“The U.S. Postal Service, Office of Inspector General, will continue to vigorously investigate those who commit frauds against federal benefit programs and the U.S. Postal Service,” said Special Agent in Charge Matthew Modafferi of the U.S. Postal Service, Office of Inspector General Northeast Area Field Office. “The sentences in this case sends a clear message to pharmaceutical companies that tactics like these will not be tolerated. The U.S. Postal Service, Office of Inspector General would like to thank our law enforcement partners and the Department of Justice for their dedication and efforts in this investigation.”
“Today’s sentencing holds the conspirators accountable for their reprehensible scheme that mislead patients and defrauded the federal government,” said Special Agent in Charge Amy K. Parker of OPM OIG. “The OPM OIG, along with our law enforcement partners, is committed to investigating individuals that seek to enrich themselves at the expense of patients, taxpayers, and the federal healthcare programs.”
Court documents and evidence at trial established that Bolos, Assad, and Palso owned and operated Synergy Pharmacy in Palm Harbor, Florida. Under their direction, Synergy employed Roix, a Florida telemarketer operating under the name HealthRight, to generate prescriptions for Synergy and the other pharmacies involved in the scheme. The prescriptions were typically for drugs such as pain creams, scar creams and vitamins. Evidence showed that to obtain the prescriptions, Roix used HealthRight’s telemarketing platform as a telemedicine service, cold-calling consumers and deceiving them into agreeing to accept the drugs and to provide their personal insurance information. HealthRight then paid doctors to authorize the prescriptions through its telemedicine platform, even though the doctors never communicated directly with the patients and relied solely on the telemarketers’ screening process as the basis for their authorizations. Because this faulty and fraudulent process made the prescriptions invalid, the drugs were misbranded under the Food, Drug and Cosmetic Act. Evidence showed that Synergy and the other pharmacies nonetheless dispensed the drugs to consumers as part of the scheme so that Bolos could submit fraudulent reimbursement claims.
Court documents and evidence at trial further established that during the conspiracy, which lasted from May 2015 through April 2018, Bolos and Palso, along with Assad, paid Roix millions of dollars to buy at least 60,000 invalid prescriptions generated by HealthRight. Evidence showed that Bolos selected specific medications for the prescriptions that he could submit for profitable reimbursements at inflated prices, and that Bolos, Palso, and Assad used illegal means to hide this activity from the PBMs so it could remain undetected.
The convictions resulted from a multi-year investigation conducted by the HHS-OIG (Nashville); FDA-OCI (Nashville); U.S. Postal Service, Office of Inspector General (Buffalo); FBI (Knoxville and Johnson City, Tennessee); OPM-OIG (Atlanta); and HSI (Tampa). The U.S. Marshals Service also assisted in the investigation and the forfeiture of assets.
Assistant U.S. Attorney Mac Heavener of the U.S. Attorney’s Office for the Eastern District of Tennessee and Senior Trial Attorney David Gunn of the Civil Division’s Consumer Protection Branch in Washington are prosecuting the case. They were assisted by Barbra Pemberton, Bryan Brandenburg and April Denard from the U.S. Attorney’s Office.
Clipped from: https://www.justice.gov/opa/pr/defendants-sentenced-tennessee-multimillion-dollar-nationwide-telemedicine-pharmacy-fraud