Tag: Fraud

MM Curator summary

[MM Curator Summary]: James Sakr stole $600k with a services not provided scam for ENT procedures.

 
 

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.

 
 

A Livingston County physician has agreed to pay more than $600,000 to resolve allegations that he fraudulently billed Medicare and Medicaid from 2014 through 2019.

U.S. Attorney Trini E. Ross said James A Sakr, an ear, nose and throat doctor with an office in Dansville, will pay $602,661.61 under an agreement announced Tuesday.

Prosecutors alleged Sakr billed the federal programs for procedures he did not perform or failed to document in patient records.

“The resolution of this case holds Dr. Sakr accountable for his actions and requires him to return the money he should not have received from Medicare and Medicaid,” Ross said. “Our office will continue to root out fraud in federal healthcare programs and hold those who defraud the public accountable.”

The civil settlement includes the resolution of claims by Dr. Lee M. Mandel under the whistleblower provisions of the False Claims Act. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. Mandel will receive a share of the settlement.

David M. Coriell, assistant U.S. attorney  for the Western District of New York, handled the case.

Officials said the U.S. Attorney’s Office coordinated with the U.S. Department of Health and Human Services Office of Inspector General and the New York State Attorney General’s Office Medicaid Fraud Control Unit.

Follow Neal Simon on Twitter @HornellTribNeal. To get unlimited access to the latest news, please subscribe or activate your digital account today.

 
 

Clipped from: https://www.eveningtribune.com/story/news/2022/06/07/dansville-doctor-settles-medicare-medicaid-fraud-allegations/10002382002/

MM Curator summary

[MM Curator Summary]: A MA fraudster stole $4.6M from Medicaid by billing for inappropriate urine tests in a kickback 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.

 
 

BOSTON — An independent clinical laboratory in New Bedford and one of its owners have been indicted on a range of criminal charges in connection with an illegal kickback and Medicaid fraud scheme involving urine drug screens at sober homes, Attorney General Maura Healey announced today.

New Bedford-based Optimum Labs, Inc. and William Owens, Jr., 60, of New Bedford, were indicted Thursday by a statewide grand jury on the charges of Medicaid False Claims (3 counts), Larceny over $1200 under False Pretenses (3 counts), and Kickbacks, Bribery, or Rebates (2 counts). Arraignment will follow in Suffolk Superior Court.

The AG’s Office alleges that Optimum referred certain of its urine drug tests to two other laboratories, Dominion Diagnostics of North Kingstown, Rhode Island and Aspenti Health of South Burlington, Vermont, in exchange for a percentage of collected insurance reimbursements in violation of the Massachusetts anti-kickback statute. 

The AG’s Office further alleges that most of Optimum’s business was urine drug testing for residential sobriety monitoring purposes at Massachusetts sober homes. Under state regulations, laboratories may not bill MassHealth for tests performed for residential monitoring purposes because such tests are not medically necessary and thus not a MassHealth covered service. In many cases, the urine drug tests were not ordered by physicians, nurses, or an appropriate authorized prescriber. By billing MassHealth and its Managed Care Entities for these tests, Optimum and Owens are alleged to have submitted, and received payment for over $4.6 million in false claims.

These charges are allegations, and all defendants are presumed innocent until proven guilty.

This matter is being handled by Assistant Attorneys General Ali Russo and Matthew Turnell, Senior Healthcare Fraud Investigator Shelby Stephens, and Investigators William Welsh and Derek Bottari, all of the AG’s Medicaid Fraud Division. Investigations Supervisor Joe Shea also provided assistance throughout this investigation. The matter was referred by MassHealth, which along with the Department of Public Health, the Department of Health and Human Services, and the Office of the Inspector General assisted with the investigation.

The AG’s Medicaid Fraud Division receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award. The remaining 25 percent is funded by the Commonwealth of Massachusetts.

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Clipped from: https://www.mass.gov/news/clinical-laboratory-and-owner-charged-in-medicaid-kickback-and-false-billing-scheme

 
 

MM Curator summary

[MM Curator Summary]: A respiratory therapist stopped providing services for a child (who still needed them), but still got paid.

 
 

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.

 
 

Attorney General Ashley Moody News Release

 
 

Attorney General Moody Announces Arrest of Respiratory Therapist Falsifying Medicaid Reports and Stealing Thousands

 
 

 
 

TALLAHASSEE, Fla.—Attorney General Ashley Moody is announcing the arrest of a respiratory therapist who defrauded the Florida Medicaid program. Attorney General Moody’s Medicaid Fraud Control Unit, with the assistance of the Osceola County Sheriff’s Office, arrested Desiree Maddox on one count of Medicaid provider fraud. Maddox falsified documentation to bilk Medicaid out of more than $4,000. Maddox worked for a home health care agency, EZ Inspiration, and provided respiratory therapy to a child Medicaid recipient and submitted timesheets for services never provided.

Attorney General Ashley Moody said, “The defendant stopped providing respiratory therapy services to a child Medicaid recipient, despite the patient’s ongoing need for treatment, and continued to bill for services not rendered. This is unacceptable and I am thankful for my Medicaid Fraud Control Unit stopping this fraud.”

According to the MFCU investigation, the owner of EZ Inspiration learned from the recipient’s doctor that the child was no longer receiving respiratory therapy despite having an ongoing need for it. When questioned, the family of the child believed that the services formerly provided by Maddox had been terminated. However, Maddox continued to submit timesheets and service notes to EZ Inspirations for four months after not providing the therapy.

Maddox faces one count of Medicaid provider fraud, a third-degree felony punishable by up to five years in prison. The State Attorney’s Office for the Ninth Judicial Circuit will prosecute this case.

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The Florida Attorney General’s Medicaid Fraud Control Unit investigates and prosecutes providers that intentionally defraud the state’s Medicaid program through fraudulent billing practices. Medicaid fraud essentially steals from Florida’s taxpayers. From January 2019 to the present, Attorney General Moody’s MFCU has obtained more than $112 million in settlements and judgments.

The Florida MFCU is funded through a grant totaling $27,734,297 for Federal Fiscal Year 2022, from the U.S. Department of Health and Human Services Office of Inspector General. The Federal Share of these funds is 75% totaling $20,800,724. The State Matching Share of these funds is 25% totaling $6,933,573 and is funded by Florida.

 
 

Clipped from: https://www.einnews.com/pr_news/573969960/attorney-general-moody-announces-arrest-of-respiratory-therapist-falsifying-medicaid-reports-and-stealing-thousands

MM Curator summary

[MM Curator Summary]: She got paid for psych assessments that never happened (but should have as part of a bariatric surgery work-up).

 
 

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.

 
 

 
 

A Colorado Springs woman who runs a mental health services business is being charged with stealing $240,000 from Medicaid, after taking payment for psychological testing services that never happened, according to the Colorado Attorney General’s Office.

Martha Sutherland, who operated Front Range Mental Health and Summit Assessments, submitted Medicaid claims and was paid for psychological testing services that never happened, according to a news release from the office of AG Phil Weiser.

An investigation by the Colorado Department of Law’s Medicaid Fraud Control Unit found that between Aug. 25, 2017, and Feb. 26, 2021, Sutherland routinely filed claims and received Medicaid reimbursement for pre-bariatric surgery mental health assessments that were not provided, according to the release.

According to the arrest warrant affidavit filed in El Paso County District Court, Sutherland also billed for the same service multiple times. The total value of the alleged theft is $240,000. 

Sutherland is charged with theft, a class three felony, and cybercrime, a class four felony.

“Medicaid provides essential health care services for many of our state’s most vulnerable residents,” Weiser said. “We will hold accountable those who would take advantage of this system for their own gain and, in turn, take resources away from those in need.”

 
 

Clipped from: https://www.csbj.com/news/springs-woman-charged-with-medicaid-fraud/article_eb763a38-d7b0-11ec-a692-8f339ed6b88d.html

MM Curator summary

[MM Curator Summary]: An outpatient SUD treatment provider paid kickbacks to residential SUD treatment providers so they could all steal Medicaid bucks.

 
 

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.

 
 

 
 

(The Center Square) – The owner of a Pennsylvania drug and alcohol treatment facility has pleaded guilty to a Medicaid fraud case that netted his organization $12 million over three years in an illegal kickback scheme.

The attorney general’s office announced the plea of Dr. Lloyd Reid, the owner of Southwest Nu-Stop Philadelphia Inc., which came about from a joint investigation of the office’s Medicaid Fraud Control Section and the U.S. Department of Health and Human Services.

Philadelphia’s Community Behavioral Health office had cited Southwest for low standards of care in the past, and a patient fatally overdosed in January 2020 in a Southwest treatment facility.

Local Trending News

“People with substance use disorder who stayed in these recovery homes were forced to attend certain substandard, outpatient treatment programs,” a press release noted. “Those outpatient treatment programs paid kickbacks to the recovery homes in return for those homes funneling patients to them, rather than giving the patients choice.”

From December 2016 to June 2019, more than $12,662,864 in Medicaid funds were sent to Southwest to provide drug and alcohol treatment. Reid then paid recovery homes over $1,178,453 in kickbacks.

The more people ushered into programs, the more Southwest could receive from Medicaid funds.

“Patients were required to live in overcrowded recovery homes and attend overcrowded group therapy sessions, including up to double the number of suggested patients for a group therapy session,” the attorney general’s office noted. “Stripping the patients of their freedom of choice, the recovery homes threatened the residents with life on the streets if they choose to attend treatment at a different facility.”

Even before the fatal overdose, Philadelphia’s CBH unsuccessfully tried to remove Southwest from its provider network.

Since 2017, when Josh Shapiro became attorney general, the Medicaid Fraud Control Section has made 560 arrests and more than $16 million in court-ordered restitution. 

Medicaid fraud is a significant financial burden on the state and federal level. The U.S. Government Accountability Office estimated that more than $57 billion of improper payments were made through Medicaid programs in 2019. The federal government funds 75% of Pennsylvania’s Medicaid Fraud unit, about $9 million for fiscal year 2022.

 
 

Clipped from: https://www.wfmz.com/news/state/medicaid-fraud-pennsylvania-treatment-facility-owner-pleads-guilty-to-12m-kickback-scheme/article_167dcd57-a101-55bc-9140-42ad03de81ec.html

 
 

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[MM Curator Summary]: The scammers paid staff to go into poor neighborhoods to get Medicaid IDs so they could submit false claims. You paid about $4M in tax dollars for this one.

 
 

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.

 
 

 
 

RALEIGH, N.C. – A Greensboro, North Carolina woman, Sharita Mathis Richardson, was sentenced today to 22 months in prison and three years of supervised release for conspiracy to commit health care fraud.  On March 25, 2021, Richardson pleaded guilty to the charge.  As part of sentencing, Richardson was also ordered to pay $2,005,531 in criminal restitution to the North Carolina Fund for Medical Assistance. 

“This defendant conspired with others to steal millions in federal funding intended to provide health care to those in need,” said U.S. Attorney Michael Easley. “Our office will continue to bring those who abuse and misuse taxpayer funds to justice.”

According to court documents and other information presented in court, between approximately 2012 and 2016, Richardson conspired with Antonio Fozard and others to defraud the North Carolina Medicaid system through the submission of over $4 million in false and fraudulent claims for the reimbursement of behavioral health services.  Medicaid is a federally funded health care benefit program that helps pay for medical-related services for low-income individuals and their families.  In North Carolina, Medicaid is administered by the North Carolina Department of Health and Human Services, Division of Health Benefits.

Fozard owned and operated a number of behavioral health companies that purported to provide services to Medicaid beneficiaries in the Middle and Eastern Districts of North Carolina.  These companies included Group Service, Inc., and Zoofari Kids, LLC.  Each of these entities engaged in a systematic effort to steal from Medicaid by billing for services that were never rendered. 

Group Service maintained offices at various times in Raleigh, Dunn, Durham, and Sanford.  Among other things, Group Service employed Reginald Van Reese, Jr., and Ruben Samuel Matos to canvas low-income neighborhoods to identify eligible Medicaid recipients and collect their personal identifying information (PII), including their Medicaid Identification numbers.  The harvested PII was then incorporated into false and fraudulent claims that Group Service submitted to Medicaid for reimbursement.  Note writers, including Humberto Mercado, were also enlisted to fabricate supporting documentation in the event of a Medicaid audit.  Richardson held herself out as Group Service’s chief operating officer and assisted Fozard in the day-to-day operations of the criminal enterprise. 

During much of the same time period, Fozard and Richardson were also managing members of Zoofari Kids, which was similarly defrauding the North Carolina Medicaid system.  Zoofari Kids operated in Durham and Garner.  The Durham location shared the same address as Group Service and purported to provide mental health treatment to Medicaid recipients.  The Garner location was strictly a drop-in daycare facility.  The daycare, however, was effectively funded by Medicaid fraud proceeds paid out to Zoofari’s mental health business.

Fozard, Reese, Matos, and Mercado each pleaded guilty to conspiracy to commit health care fraud in separate related cases.  Reese, Matos, and Mercado were previously sentenced to terms of imprisonment and ordered to pay restitution to the North Carolina Fund for Medical Assistance.  Fozard is scheduled to be sentenced during the term of court that begins on July 20, 2022.

Michael Easley, United States Attorney for the Eastern District of North Carolina, made the announcement after sentencing by United States District Judge Louise W. Flanagan. The Federal Bureau of Investigation and the Medicaid Investigations Division of the North Carolina Department of Justice investigated the case.  Assistant United States Attorney Adam F. Hulbig prosecuted the case for the government.

Related court documents and information can be found on the website of the U.S. District Court for the Eastern District of North Carolina or on PACER by searching for Case No. 5:20-CR-506-FL.

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Clipped from: https://www.justice.gov/usao-ednc/pr/greensboro-resident-sentenced-conspiring-defraud-north-carolina-medicaid-system

 
 

MM Curator summary

[MM Curator Summary]: Momma paid her son Medicaid bucks for work he didn’t do.

 
 

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.

 
 

Vermont Business Magazine The Attorney General’s Office announced that the Caledonia Criminal Division found probable cause for felony Medicaid Fraud charges committed by Debra Stewart, 62, of Newark, Vermont, and her son, Andrew Lavelle, 31. Ms. Stewart was arraigned today on two counts of Medicaid Fraud, while the court issued an arrest warrant for Mr. Lavelle. The charges brought against both Ms. Stewart and Mr. Lavelle are the result of an investigation conducted by the Attorney General’s Medicaid Fraud and Residential Abuse Unit. 

Ms. Stewart was a contracted shared living provider for two vulnerable adults under Vermont Medicaid’s Developmental Services Waiver program. It is alleged that Ms. Stewart, in her role as employer, hired her son, Mr. Lavelle, as a respite provider and signed timesheets asserting that the vulnerable adults in her care received services from Mr. Lavelle when, in fact, Mr. Lavelle had not provided those services. The State alleges that Mr. Lavelle received over $4,000 based on those false timesheets. 

Ms. Stewart pleaded not guilty at her arraignment in Vermont Superior Court, Caledonia Criminal Division. The Court, Judge Justin Jiron presiding, ordered conditions of release which prohibit Ms. Stewart from providing care for any vulnerable adult without first receiving approval by the court.

Medicaid Fraud holds the potential for a maximum of ten years of incarceration and a fine of up to $1,000 or an amount equal to twice the amount of payments wrongfully obtained or both. 

The Attorney General’s Office emphasizes that individuals charged with a crime are legally presumed innocent until their guilt is proven beyond a reasonable doubt in a court of law.

The Medicaid Fraud and Residential Abuse Unit receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $1,057,724 for Federal fiscal year FY 2022. The remaining 25 percent, totaling $352,575 for FY 2022, is funded by the State of Vermont.

5.23.2022. MONTPELIER – Attorney General

 
 

Clipped from: https://vermontbiz.com/news/2022/may/23/mother-and-son-charged-medicaid-fraud

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

 
 

MM Curator summary

[MM Curator Summary]: The fraudster filled using generics and billed for brand.

 
 

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.

 
 

 
 

A Neligh woman is set to make her first court appearance next month after a grand jury in Omaha indicted her on suspicion of defrauding the government of more than half a million dollars.

Danelle Charf, 47, is charged in a five-count indictment for health care fraud.

If convicted, she would face up to 10 years in prison and a $250,000 fine for each charge.

In court records, Assistant U.S. Attorney Kelli Ceraolo said Charf, a pharmacist, owned and operated Wanek Pharmacy in Neligh and Tilden Pharmacy in nearby Tilden.

The indictment alleges that, beginning as early as January 2016 and continuing until Jan. 27, 2021, Charf submitted fraudulent claims to Medicare and Nebraska Medicaid.

Ceraolo said Charf filled prescriptions at Wanek and Tilden pharmacies with the generic version of certain medications, then submitted claims seeking reimbursement for the more expensive brand-name versions of the medications.

As a result of the scheme, prosecutors say she caused losses of at least $573,300 to Medicare and Nebraska Medicaid.

 
 

Clipped from: https://norfolkdailynews.com/state/nebraska/neligh-pharmacist-facing-indictment-for-573k-health-care-fraud/article_1ecbb01d-dadc-5ed5-9f1c-5973970c801a.html

MM Curator summary

[MM Curator Summary]: A pharmacy scheme run in locations owned by a former legislator stole $2.7M from 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.

 
 

 
 

A former Kentucky legislator pleaded guilty in federal court Wednesday to health care fraud and a financial crime.

Robert Goforth, 46, admitted that a pharmacy he owned in Clay County billed insurance programs, including Medicare and Medicaid, for prescriptions that customers didn’t pick up.

The medication could then be put back on the shelf and sold again.

“I knew that it was wrong and I’m here to own up to that and take responsibility for my actions,” Goforth said in a hearing before U.S. District Judge Robert E. Wier in London.

Goforth agreed as part of his plea not to appeal any sentence up to three years and one month in prison.

Goforth pleaded guilty to one charge of health care fraud and one charge related to money laundering, acknowledging he wrote a $17,000 check from an account that contained at least some money derived from the fraud.

Each charge carries a maximum sentence of 10 years in prison. Goforth’s sentence will likely be less than that under advisory guidelines.

Federal prosecutors charged Goforth by way of a document called an information. That is a way to file a charge without presenting the case to a grand jury.

Goforth said at the hearing a state pharmacy investigator told him in 2015 about suspected fraud by an employee involving prescriptions not being picked up.

The employee received a percentage of the store’s profits, Goforth said.

Goforth said the normal procedure if a customer didn’t pick up a prescription would be to credit the charge back to the insurance provider.

However, after looking into the situation and seeing discrepancies, he ignored the problem and allowed the improper billing to continue for several months, Goforth said.

“I had a responsibility to stop it and I did not do that,” he said in court.

Goforth conceded in his plea agreement that about $2.7 in excessive billing occurred at the Manchester pharmacy from when he started it until he sold it in September 2016. Of that, about $1.35 million happened after he was put on notice about the problem.

Most of his business came from Medicare and Medicaid, meaning that after he was notified of the fraud, there was $945,000 in false billing to the government programs, according to the plea agreement.

The total restitution in the case is $2.7 million.

Wier could have ordered Goforth detained until sentencing, but allowed him to remain out of jail. Prosecutors had agreed to recommend allowing him to remain free.

Wier scheduled sentencing in September.

Goforth, a Republican, represented Jackson County and parts of Laurel and Madison counties in the state House before resigning in August 2021 as he faced a charge in state court of strangling his wife during a domestic dispute in April 2020.

That charge is pending.

Goforth also ran unsuccessfully for the GOP nomination for governor in 2019.

This story was originally published May 25, 2022 4:36 PM.

 
 

Clipped from: https://www.kentucky.com/news/local/crime/article261794992Rober.html