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FRAUD, EXPANSION (NC)- Scams reported ahead of N.C. Medicaid expansion

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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.


[MM Curator Summary]: Fraudsters are already exploiting the upcoming expansion of Medicaid in N.C. by communicating to existing and potential members they need to pay money to maintain Medicaid eligibility.


Clipped from:–medicaid–scams–healthcare–north-carolina-medicaid-expansion

North Carolina’s new state budget will expand Medicaid, making 600,000 additional people eligible for coverage.

What You Need To Know

  • The Better Business Bureau says it has received reports of scammers soliciting people who may qualify for Medicaid under North Carolina’s expansion


  • The BBB says it’s an attempt to steal identities and money


  • Scammers are also scaring people into believing they’ll lose Medicare benefits

The Better Business Bureau says it has gotten reports about scammers posing as government officials going after residents’ personal information ahead of Medicaid officially expanding on Dec. 1.

BBB president and CEO Tom Bartholomy says people who think they may be eligible for the federal program can be targets for scammers. They’re using emails, texts and social media to get through to potential victims.

“Anybody who’s not been in Medicaid before is going to go, ‘OK, maybe this is how I get going on this,'” he said. “But it’s really not the case. This is just a scammer that’s posing as state-sanctioned Medicaid expansion and they’re really just there to steal your money and steal your identity.”

Even if Medicaid isn’t on your radar, Bartholomy says con artists have other ways to get to you.

“Their other angle now is that with Medicare, open enrollment is starting on Oct. 15, and so they’re reaching out to people who are Medicare age,” he said.

He says the impostors are threatening to take away benefits unless you “take action” right away.

He recommends going directly to the government’s websites to learn more.

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FRAUD (AK)- Alaska Medicaid fraud investigation leads to indictment for Kenai doctor and staff

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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.


[MM Curator Summary]: 23 people in AK conspired to steal Medicaid dollars using fraudulent bills to the state and MCOs.



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The exterior of the Nesbett Courthouse in downtown Anchorage on August 31, 2022. (Valerie Kern/ Alaska Public Media)

A Kenai doctor and his clinics’ managers face nearly two dozen felony charges in an alleged Medicaid fraud case after a grand jury indicted them Wednesday.

Prosecutors say Dr. Ray Lynn Carlson, owner of MediCenter clinics on the Kenai Peninsula, fraudulently billed Alaska Medicaid and two insurance companies – Aetna and Premera – from 2014 to 2019.

Also named in the indictment are Scott Carlson, Charise Carlson and Joseph Hurley, as well as a corporation in Ray Carlson’s name, under which he owned two MediCenter clinics, one in Kenai and one in Nikiski.

Each of the defendants faces 23 criminal counts, including fraud, theft and fraudulent insurance acts.

There is limited information about the alleged fraud in the grand jury’s indictment, but it indicates the defendants overbilled Medicaid and the insurance companies and, in at least some instances, submitted false medical billing codes.

Carlson’s MediCenter clinics appear to have closed sometime after the Alaska Medicaid Fraud Control Unit’s investigation began. According to a Peninsula Clarion newspaper story from 2019, investigators had searched MediCenter’s offices that July.

Phone numbers at both clinics are now disconnected. None of the defendants had attorneys listed in court records as of Friday.

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FWA (KY)- Oxygen Plus to pay $200,000 to resolve allegations of bilking Medicare, Medicaid

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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.


[MM Curator Summary]: 2 whistleblowers tipped off investigators about the company’s bogus billing for vent machines.



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STANVILLE, Ky. — A Floyd County company has agreed to pay $200,000 to resolve allegations that it defrauded the government by billing for unnecessary medical equipment.

The U.S. Attorney’s Office for the Eastern District of Kentucky announced the settlement on Tuesday.

Oxygen Plus, based in Stanville, rents non-invasive ventilators for patients with severe respiratory diseases to use at home. The company was accused of submitting more than 300 false claims to Medicare and Medicaid between 2017 and 2021, by continuing to bill for the rentals even after the patients were no longer using them.

The allegations were brought to light by two whistleblowers who worked at the company as a respiratory therapist and a bookkeeper. They accused the company of pressuring employees to solicit Medicare and Medicaid beneficiaries to rent the machines.

The lawsuit lists five patients who were given lifetime prescriptions for the ventilators, despite not showing symptoms to support a diagnosis of respiratory failure. One of those patients was never examined by a doctor.

For reporting the false claims to the government, the whistleblowers will split a $32,000 share of the settlement.

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FRAUD (FL)- 20 arrested, accused in $5 million Medicaid transportation scheme involving Jacksonville company

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[MM Curator Summary]: The GPS systems in their vehicles helped get the conviction.




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20 arrested, accused in $5 million Medicaid transportation scheme involving Jacksonville company

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20 arrested, accused in $5 million Medicaid transportation scheme involving Jacksonville company

JACKSONVILLE, Fla. – Florida Attorney General Ashley Moody said in a statement Thursday that 20 people have been arrested in a $5 million Medicaid scheme involving a Jacksonville transportation company.

RELATED | I-TEAM: Patients left stranded by non-emergency medical transportation provider

Many of the suspects are from Jacksonville, including Jose Hernandez Fernandez, who is the owner Sweet Transportation.

Investigators said the company, which provided non-emergency transportation for Medicaid recipients, billed Medicaid for thousands of patient trips that never happened. The trips were supposed to help patients receive medical care.

Hernandez Fernandez is accused of fraud, racketeering and money laundering.

The Medicaid transportation system has received plenty of complaints and was the subject of an I-TEAM investigation last year.

According to investigators, Jose Hernandez Fernandez started Sweet Transportation in 2019, and in 2020, when the company had just two drivers, it contracted with Modivcare, which is a vendor with the state to coordinate transportation for Medicaid patients. It was in 2022, investigators said, that Sweet Transportation reached its peak of 30 drivers.

The I-TEAM has previously reported on concerns about Modivcare and their various subcontractors arriving late for appointments or not at all.

On Thursday, News4JAX spoke again with Rene Reynolds, who said that her 84-year-old father struggled to get reliable transportation from Modivcare before his death earlier this year.

“It gives me a little bit more encouragement that there are good things that happen when somebody speaks up, me and other people speak up,” Reynolds said.

She said she’s not sure if Modivcare ever assigned Sweet Transportation to transport her father because she typically wasn’t made aware of which subcontractors were providing him rides.

According to investigators, Sweet Transportation drivers would bill for trips that never happened and inflate mileage for trips they did complete, but they were busted with help from the mandatory GPS technology installed in their vehicles.

In a separate civil lawsuit filed by the attorney general’s office, investigators said Hernandez Fernandez charged Florida Medicaid for nearly 3,000 trips as a driver in the Jacksonville area when he was actually in South Florida, Georgia, New York, Massachusetts, Colorado, Nebraska, Kansas and Puerto Rico.

“It’s refreshing to know that there is there is some justice out, there but I think it’s a drop in the bucket this fellow I think that there’s plenty more,” Reynolds said.

Hernandez Fernandez and 20 employees of Sweet Transportation are all accused of participating in the Medicaid scheme and are facing criminal charges and named in a civil racketeering lawsuit brought by the state.

According to police records, the investigation into Sweet Transportation began after United Health Care, which manages Medicaid services, complained about possible fraud.

A spokesperson for Modivcare sent the I-TEAM a statement Thursday, stating, “Modivcare has fully cooperated with the [Attorney General’s] Medicaid Fraud Control Unit (MFCU) through the entirety of this investigation.”

News4JAX tried to reach Hernandez Fernandez’s attorney but has not yet received a response.

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Edgewater Systems to pay $1.25M in Medicaid claims settlement

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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.


[MM Curator Summary]: The counseling firm failed to get sign off from qualified providers on individualized care plans.



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Tuesday, October 3, 2023 12:30 PM EDT

By Carley Lanich


(Adobe Stock Photo)

HAMMOND, Ind. – A Gary-based health care provider is expected to pay the state $1.25 million to resolve claims the company fraudulently billed the Indiana Medicaid program for mental health services.

U.S. Attorney Clifford Johnson’s office announced in a press release that state and federal officials reached a settlement with Edgewater Systems for Balanced Living to resolve civil claims brought against the company.

The Indiana Medicaid program — which provides services to low-income, often uninsured Hoosiers — is funded jointly by the state and federal government.

Story Continues Below

Federal officials say Edgewater repeatedly billed Indiana Medicaid for mental health counseling sessions that failed to meet a requirement stating providers must draft an individualized care plan signed by a qualifying physician or health service provider before billing Medicaid.

Officials say the billing occurred between November 1, 2012 and December 31, 2017. They also said they believed Edgewater should have been aware of the billing requirement due to past negative audits.

Assistant U.S. Attorney Wayne T. Ault handled the settlement negociation following an investigation initiated by the northern district court and conducted with assistance from the Indiana Attorney General’s Medicaid Fraud Control Unit.




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Carr: Child Behavioral Health Counselor Convicted of Medicaid Fraud

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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.


[MM Curator Summary]: Mr. Lacey’s shenanigans were first noticed by Wellcare. MCO fraud referrals do happen.




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ATLANTA, GA – Attorney General Chris Carr today announced that Antonio Lacey, 47, a behavioral health counselor in Locust Grove, has been convicted of repeatedly submitting false claims to the Georgia Medicaid program for which he obtained $45,212. A Henry County Superior Court Judge sentenced the defendant to five years, with six months to be served in prison and the remainder on probation.

“Mr. Lacey used his role as a children’s counselor to defraud our state’s Medicaid program,” said Carr. “He placed personal greed above his responsibilities as a provider, and in the process, he broke the trust of Georgia families in need of services. Now he will spend time behind bars for his illegal actions, and we will continue our efforts to protect taxpayer dollars no matter the amount.”

Antonio Lacey Guilty Plea

On Aug. 15, 2023, Lacey pleaded guilty to both counts of the indictment brought by the Attorney General’s Medicaid Fraud Division:

  • Medicaid Fraud in violation of O.C.G.A. § 49-4-146.1 (b)(1)
  • False Statements and Writings in violation of O.C.G.A. § 16-10-20

Lacey paid restitution in the amount of $45,212 at the time of his plea.

Case Summary

Lacey was enrolled in Georgia Medicaid as a provider of behavioral health services for children who cannot afford care. In a routine audit of Lacey’s practice, Wellcare, a care management organization working under contract with Georgia Medicaid, reported the lack of documentation and parents’ denial of services to the Georgia Department of Community Health (DCH). DCH referred the case to the Attorney General’s Medicaid Fraud Division for further investigation. Their findings resulted in a two-count indictment against Lacey for submitting claims for which no services had been provided.

This case was investigated by Medicaid Fraud Division Investigators Ulecia Daniel and Wilner Piquant, along with Investigative Auditor Phoenecia Hunt and Intel Analyst Zwella Boyd. The case was prosecuted by Senior Assistant Attorney General Henry Allen Hibbert.

About the Attorney General’s Medicaid Fraud Division

The Attorney General’s Medicaid Fraud Division receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $4,718,240 for Federal fiscal year (FY) 2023. The remaining 25 percent, totaling $1,607,601 for FY 2024, is funded by the State of Georgia.

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FRAUD (WA)- West Richland WA couple accused of $700,000 in Medicaid fraud

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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.


[MM Curator Summary]: A husband and wife couple stole a ton of cash. This story even includes a few good ole fashioned stake outs.



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By Cameron Probert

September 30, 2023 5:00 AM

Richland, WA

A West Richland couple allegedly led a criminal organization that bilked Medicaid for more than $700,000, according to a Washington state investigation.

Cloreese Wilkinson-Rivera, 46, and Carlos P. Rivera, 44, allegedly spent three years creating phantom therapy appointments, billing the wrong amounts to insurance companies and charging for appointments that never happened, according to recently filed court documents.

They used the money to pay for their home and at least five luxury cars, including two Ferraris and a Lamborghini.

After a lengthy investigation, the Washington State Attorney General’s Office filed 17 counts against the couple in Benton County Superior Court.

They are accused of leading a criminal organization, five counts of theft, five counts of money laundering and submitting false statements to Medicaid.

Wilkinson-Rivera also faces one count of forgery.

They have both been summoned to court to enter pleas to the charges on Oct. 19.

The couple ran Tri-Cities Marital and Family Therapy from an office building on Stevens Drive in Richland, according to public records.

The investigation also includes a Kennewick location where they operated previously.

Wilkinson-Rivera led a team of counselors, and Rivera ran the business, including billing, according to court documents.

Wilkinson-Rivera has had a lengthy career providing mental health services that began in 2004, according to her profile on Psychology Today. She has served as a bilingual clinician, a vocational rehabilitation counselor, a daycare provider and a hospital case manager.

Department of Health records say she became a licensed mental health counselor in 2015, and, according to the state attorney general, the alleged theft started shortly after.

Fraudulent billing

The state’s Medicaid Fraud Control Division started investigating the couple after getting a tip from a former co-worker, said Special Agent Ses Maiava in an affidavit.

The tipster said Wilkinson-Rivera was double billing for services not rendered. That including billing an entire family for therapy, but only treating one person.

Investigators soon discovered the couple was submitting Medicaid billing claims that misrepresented what they were doing, and raked in $710,000 between January 2016 and June 2019.

That included billing for patients who missed, skipped or canceled appointments, using incorrect billing codes, and submitting claims for hour-long sessions that were, in reality, much shorter.

The alleged fraudulent billing also included people who were never treated by anyone at the Tri-Cities Marital and Family Therapy.

“Sometimes these billings would correspond with family member’s treatments, but other times there would be a claim that was paid without any reason for it to be billed,” Maiava wrote. “I refer to these claims as ‘Phantom Billings.'”

Billing more than 24 hours

After getting the tip, a fiscal expert went through the billing statements that Wilkinson-Rivera had sent in and allegedly found she would have been working for more than 24 hours in a day.

State investigators watched Wilkinson-Rivera go into the office during three separate three-day periods in October 2018, January 2019 and March 2019. Each time, she billed for dozens of hours that she wasn’t working at the building.

During the surveillance in January, agents counted 44 people enter the facility, while Medicaid billing records allegedly showed them treating 133.

The records also showed she allegedly billed a family of five who had a group therapy, as if each member was treated during a separate 60-minute session.

In another case during the January period, a family of five was billed for a therapy session they never attended. In another family, one child received therapy, but then the child’s two siblings were also billed for individual hour-long sessions.

Investigators also searched the therapy office, Wilkinson-Rivera and Rivera’s home and got email and cellphone records.

As they searched the records, they found a number of appointments which were allegedly billed for an hour, but they only spent a half-hour on the phone.

In addition, they allegedly discovered that there were online or phone therapy sessions that were billed as if they were in person. Emails between the couple showed them encouraging or directing employees to use phone sessions to increase billing.

They also found the insurance was billed for appointments that were canceled or missed.

“(Text) messages from Cloreese Wilkinson-Rivera to Carlos Rivera show they wanted to make as much money as possible after Cloreese Wilkinson-Rivera complains about working 50 hours and making little money in 2016,” according to court documents.

Phantom sessions

The bulk of the alleged fraud, more than $466,000, were for “phantom sessions.”

One of the examples listed was for a family of five people who were billed $23,000 for sessions that allegedly didn’t happened. One of the parents said she didn’t take her children to appointments during work hours for weekly sessions in the summer.

“The calendar entries show 417 of these sessions were phantom sessions or sessions that did not occur,” according to the affidavit.

In addition to the false bills, the couple also applied for health benefits from Medicaid for each other and each of their children between 2016 and 2019.

Fancy cars and house

The couple is accused of funneling the fraudulent payments into making car and mortgage payments.

While their West Richland home is now valued at more than $1 million, according to the Benton County Assessor’s Office, they paid $270,000 when they bought it in 2014.

According to court documents, they spent $112,000 on mortgage payments and $137,000 in car payments.

Among the car payments, there were five luxury cars they were paying for, including a 2004 Lamborghini Gallardo, a 2001 Ferrari Modena and a 1996 Ferrari.

Each of the cars can sell for between $80,000 and more than $100,000, according to CarFax.

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PHE- COVID-19 Provider Relief Fund: HRSA Continues to Recover Remaining Payments Due from Providers

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[MM Curator Summary]: HRSA is on the strugglebus trying to get some of the COVID Provider Relief Funds back. Roughly $2.6B of them to be exact-ish.



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Fast Facts

The Provider Relief Fund spent $135 billion to help health care providers with COVID-related expenses and lost revenue during the pandemic. Most of the relief payments—about $85 billion—went to hospital-based health systems and hospital-affiliated providers.

To confirm that payments were accurate, the Health Resources and Services Administration took steps to review provider eligibility and if funds were used appropriately. In doing so, it found that $2.6 billion in payments should be recovered.

As of May 2023, the agency had recovered about half of the money and, as of August 2023, had set a schedule to get back the rest.


What GAO Found

The Health Resources and Services Administration (HRSA), an agency within the Department of Health and Human Services (HHS), administers and oversees the Provider Relief Fund (PRF). The PRF provided relief to health care providers for expenses or lost revenues attributable to the COVID-19 pandemic. As of May 2023, HRSA distributed $135 billion in payments kept by providers; hospital-based health systems and hospital-affiliated providers received the majority of payments—about $84 billion. HRSA made payments until June 2023, when the remaining unobligated funds for provider relief payments were rescinded

Among its efforts to ensure payment accuracy, HRSA conducted pre-payment reviews to verify provider eligibility and information on provider applications. HRSA also conducted post-payment reviews to check for potential payment errors and identify overpayments. HRSA plans to conduct these reviews on 59 types of potential payment errors, but the agency has been delayed in completing these reviews. As of May 2023, 21 of 59 remained open. In October 2021, GAO recommended that HRSA promptly complete the remaining reviews, but HRSA has not yet implemented the recommendation.

HRSA has taken steps to ensure that providers used PRF payments according to program requirements. HRSA required providers to report on their use of PRF payments, and it has been auditing a risk-based sample of providers to verify appropriate use of payments. HRSA also assessed fraud risks and implemented controls to ensure proper use of payments, though certain processes were only recently implemented. In particular, HRSA implemented recommendations from its 2021 fraud risk assessment. In March 2023, HRSA implemented a process to review irregular payments and, in June 2023, finalized procedures for responding to potential fraud.

As of May 2023, HRSA had recovered about half of the $2.62 billion in payments identified for recovery. HRSA had established time frames to recover most of the $1.36 billion in payments not yet recovered, but had not established time frames to recover $250 million in remaining overpayments, unused payments, and some payments from non-compliant providers. However, in August 2023, HRSA established time frames for the recovery of these payments.

Provider Relief Fund (PRF) Payment Recoveries, as of May 2023

Why GAO Did This Study

The PRF was created in March 2020 to provide COVID-19 relief to health care providers and ensure access to essential health care services. Providers included those enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program.

The CARES Act includes a provision for GAO to monitor and report on the federal response to the COVID-19 pandemic. This report describes (1) PRF payment distributions; and examines (2) efforts to ensure the accuracy of PRF payments, (3) efforts to ensure that PRF payments were used according to program requirements, and (4) the status of efforts to recover PRF payments.

GAO analyzed data on PRF payments as of December 2022, by which time nearly all PRF payments had been distributed. GAO analyzed recoveries of PRF payments as of May 2023—the most recent data available at the time of the review. GAO also reviewed information and agency documentation on payment integrity activities, including program reports and risk assessments; interviewed agency officials; and compared payment integrity activities to agency requirements.

GAO’s draft report recommended that HRSA establish time frames to promptly recover remaining overpayments, unused payments and payments from all noncompliant providers. In response to the draft report, in August 2023, HRSA provided a time frame for the recovery of these payments. As a result, GAO removed the recommendation and modified the report accordingly.

For more information, contact Leslie V. Gordon at (202) 512-7114 or

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FRAUD (TX)- Texas couple allegedly scammed Medicaid out of $14 million by fixing the same wheelchairs hundreds of times

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[MM Curator Summary]: The Yzaguirres stole $14M of your tax dollars thru a DME scam.



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By Lukas I. Alpert

Jeremiah and Maria Yzaguirre are accused of using the money to buy luxury cars, real estate and pricey movie memorabilia

A Texas couple has been charged with ripping off Medicaid to the tune of $14 million by claiming to have repaired the same handful of motorized wheelchairs hundreds of times.

Many of the claims were made for patients who were bedridden and unable to use the wheelchairs at all, according to fraud, money-laundering and identity-theft charges filed in federal court in Brownsville, Texas.

Federal prosecutors accuse Jeremiah Yzaguirre, 44, and his wife, Maria Luisa Yzaguirre, 43, of Harlingen, Texas, of making the claims on behalf of 37 people who had been customers of their medical device company, Southwest Medical Homepatient.

The pair are accused of then using the proceeds of the alleged scam to buy a luxury $150,000 Acura NSX sports car, high-priced real estate and hundreds of thousands of dollars worth of cryptocurrency. They also allegedly amassed a collection of expensive movie memorabilia including a Johnny 5 robot prop from the 1986 film “Short Circuit,” worth over $100,000.

An attorney for Jermiah Yzaguirre, who was arrested on Aug. 22 on a sealed indictment, didn’t immediately respond to a message seeking comment. Maria Yzaguirre was arrested Wednesday morning and it wasn’t immediately clear if she had retained an attorney. She is expected to make her first appearance in court on Thursday afternoon, prosecutors said

According to court filings, between 2019 and 2023 the couple submitted claims on several occasions for hundreds of the same repairs to the same wheelchairs.

In one case, the Yzaguirres are accused of submitting over 300 repair claims for the same wheelchair, including 132 to fix its expandable controller, 107 to fix its motor gearbox and 84 to replace its battery.

According to court documents, prosecutors have asked the judge to allow them to seize hundreds of thousands of dollars in cryptocurrency wallets and regular cash accounts, the Acura sports car, drone equipment and a long list of valuable anime figurines and movie-themed Lego sets the couple owned.

If convicted, the Yzaguirres each face up to 10 years in prison for fraud and money laundering and two years for each count of aggravated identity theft.

-Lukas I. Alpert

This content was created by MarketWatch, which is operated by Dow Jones & Co. MarketWatch is published independently from Dow Jones Newswires and The Wall Street Journal.

(END) Dow Jones Newswires

09-02-23 0902ET

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FRAUD (MN)- Ellison’s office has charged 18 with Medicaid fraud that netted nearly $10 million

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[MM Curator Summary]: This one had lots of features, including a giant “services not provided” bill for personal care services and a check-cashing scheme.



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Five people face charges in an alleged scheme to defraud the Minnesota Medical Assistance program of nearly $10 million.

The complaints filed in Hennepin County District Court allege owners and employees of a personal care company called MN Professional PCA billed for services that were not performed and for services that were not supervised by a nurse or other qualified professional.

Owners Abdikarim Mohamed and Ahmed Nur, along with three managers of MN Professional, are charged with racketeering, engaging in business of concealing criminal proceeds, and aiding and abetting theft by swindle.

The fraudulent activity is alleged to have occurred between 2016 and 2021.

Minnesota Attorney General Keith Ellison called the case the largest Medicaid fraud prosecution by his office.

A total of 18 people have been charged as part of the ongoing investigation.

The complaint alleges the company billed Medicaid for more than 25,000 hours of services that were not provided.

The company also provided services not supervised by a professional to at least 120 clients.

The total alleged fraud is about $9.5 million, according to Ellison.

The complaint alleges the men concealed the fraudulent payments through an elaborate check-cashing scheme.

Investigators said Mohamed and Nur also fraudulently listed their wives as “board members” and “consultants” and paid them salaries amounting to hundreds of thousands of dollars.

To date, 18 people have been charged as part of the investigation, and five have pleaded guilty.

The investigation was led by the Medicaid Fraud Control Unit in the attorney general’s office and the U.S. Department of Health and Human Services’ Office of Inspector General.

The attorney general’s office said additional charges are expected as the investigation continues.