Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 1 of 55. PageID #: 1

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1 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 1 of 55. PageID #: 1 IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF OHIO EASTERN DIVISION UNITED ST A TES OF AMERICA, v. Plaintiff, PHYSICIANS SURGICAL GROUP, LLC, CHRISTOPHER LIV A, EDWARD LIV A, CAROLYN VIA, aka CAROYLN LIV A, MARK FRITZ, JOHN NICKELS, JOHN FORTUNA, and ANTHONY SIMONE, Defendants.. ) INDICTMENT ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) 1: 14CR4471 Title 18, Sections 1343, 1347, 1349, 1956, United States Code JUDGE,l\DAMS The Grand Jury charges: I. GENERAL ALLEGATIONS At all times material to this Indictment, except where otherwise noted: A. Defendants, Businesses, and Bank Accounts I. Defendant PHYSICIANS SURGICAL GROUP, LLC (hereinafter "PSG") was a Florida Limited Liability Company (hereinafter "LLC") with its principal place of business at 40 SE 5th Street, Suite 406, Boca Raton, Florida. PSG was formed in 2006, and was primarily a billing company for medical services. PSG was owned by CHRISTOPHER LIV A (hereinafter,

2 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 2 of 55. PageID #: 2 "CHRIS LIV A"), EDWARD LIVA (hereinafter, "ED LIV A"), and CAROLYN VIA aka CAROLYN LIV A (hereinafter, "CAROL VIA") Surgical Group (hereinafter "7431," and together with PSG, the "PSG Entities") was a Florida LLC with its principal place of business at 40 SE 5th Street, Suite 406, Boca Raton, Florida was formed in 2008 and was in the business of providing payroll and billing services was voluntarily dissolved on August ], was owned by CAROL VIA. 3. Liva Associates was a Florida LLC with its principal place of business at 6418 La Costa Drive, Apt 101, Boca Raton, Florida Liva Associates was formed in Liva Associates was owned by CHRIS LIVA and others known and unknown to the Grand Jury. 4. Physician's Marketing & Management was a Florida LLC with its principal place of business at 40 SE 5th Street, Suite 406, Boca Raton, Florida. It was owned by CAROL VIA. 5. Shaker Heights Surgical Center (hereinafter "SHSC") was an Ohio corporation with its principal place of business at 3235 Lee Road, Shaker Heights, Ohio. SHSC was formed on or about December 19, 2007, and operated an ambulatory surgical center licensed by the State of Ohio. SHSC was owned by CHRIS LIV A, ED LIV A, CAROL VIA, John K., David N., Arthur H., and Michael A. 6. Anesthesia Company of America (hereinafter "ACA") was a Florida LLC with its principal place of business at 201 Montgomery A venue, Sarasota, Florida. ACA was formed in 2007 and was in the business of providing billing services related to medical procedures involving anesthesia. ACA was owned by Carl. N. ACA employed JOHN NICKELS to serve as the anesthesiologist at SHSC. 7. ECSC III (hereinafter "ECSC," and together with ACA, the "ACA Entities") was a Florida LLC with its principal place of business at 20 I Montgomery Street, Sarasota, Florida 2

3 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 3 of 55. PageID #: ECSC was formed in According to its articles of incorporation, ECSC's managing members were Carl N., Bradley W., and E&C Consultants of Boca Raton. ACA, ED LIVA, and CHRIS LIV A formed ECSC, which was defined as "Edward Chris Spine Care." Ownership in ECSC was split between ACA, ED LIV A, and CHRIS LIV A. 8. E&C Consultants of Boca Raton (hereinafter "E&C") was a Florida LLC with its principal place of business at 280 Royal Palm Way, Boca Raton, Florida E&C was formed in According to its articles of incorporation, E&C's managing members were CHRIS LIV A and CAROL VIA. 9. Defendant CHRIS LIVA was a resident of Boca Raton, Florida. 10. Defendant ED LIV A was a resident of Boca Raton, Florida. 11. Defendant CAROL VIA (together with CHRIS LIV A and ED LIV A, the "LIV AS") was a resident of Boca Raton, Florida. 12. The LIV AS were de facto, if not actual, owners of SHSC and PSG during some or all of the period PSG and SHSC submitted claims for manipulation under anesthesia ("MUA'') procedures to the Insurers (described below) arid received the bulk of distributions of profits from PSG for the MUA procedures. 13. Defendant MARK FRITZ (hereinafter "FRITZ") was a resident of Coral Springs, Florida, and was the manager and Chief Financial Officer of PSG. 14. Defendant JOHN NICKELS (hereinafter "NICKELS") was a licensed medical doctor and anesthesiologist in the State of Ohio and a resident of Ohio. 15. Defendant JOHN FORTUNA (hereinafter "FORTUNA") was a licensed chiropractor in the State of Ohio and a resident of Avon, Ohio. 16. Defendant ANTHONY SIMONE (hereinafter "SIMONE"), was a licensed chiropractor in the State of Ohio and a resident of Cleveland, Ohio. 3

4 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 4 of 55. PageID #: On or about July 8, 2008, CAROL VIA opened and caused to be opened bank account number x8947 at Northern Trust in the name of Physician's Marketing & Management. CAROL VIA was listed on the signature card for this account. 18. On or about October 21, 2008, CAROL VIA and CHRIS LIVA opened and caused to be opened bank account number x2853 at Northern Trust in the business name of E&C. CAROL VIA and CHRIS LIV A were listed on the signature card for this account. 19. On or about June 24, 2008, Arthur H. and CHRIS LIV A opened and caused to be opened bank account number x2735 at Northern Trust in the business name of SHSC. Arthur H. and CHRIS LIV A were listed on the signature card for this account. On or about March 30, 2009, CAROL VIA was also added as an account signer for bank account number x On or about August 16, 2007, CAROL VIA opened and caused to be opened bank account number x9303 at Northern Trust in the name of CAROL VIA. CAROL VIA was listed on the signature card for this account. 21. On or about August 11, 2006, CAROL VIA opened and caused to be opened bank account number x8936 at Northern Trust in the name of CAROL VIA. CAROL VIA was listed on the signature card for this account. 22. On or about September 13, 2007, CHRIS LIVA opened and caused to be opened bank account number x9046 at Northern Trust in the business name of Liva Associates. CHRIS LIV A was listed on the signature card for this account. B. Private Insurers 23. Medical Mutual of Ohio (hereinafter "MM") was an Ohio corporation with its principal place of business in Cleveland, Ohio. MM provided health care benefits and insurance to its subscribers under individual and group health insurance plans, and provided this insurance under a variety of coverage options set forth in the benefit plans. 4

5 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 5 of 55. PageID #: Anthem Blue Cross and Blue Shield ("Anthem") provided health care benefits and insurance to its subscribers under individual and group health insurance plans, and provided this insurance under a variety of coverage options set forth in the benefit plans. 25. United Healthcare ("United") provided health care benefits and insurance to its subscribers under individual and group health insurance plans, and provided this insurance under a variety of coverage options set forth in the benefit plans. 26. Aetna provided health care benefits and insurance to its subscribers under individual and group health insurance plans, and provided this insurance under a variety of coverage options set forth in the benefit plans. 27. MM, Anthem, United, and Aetna (collectively, the "Insurers") were health care benefit programs under Title 18, United States Code, Section 24(b ). C. Reasonable and Necessary Services 28. The Insurers prohibited payment for items and services that were not reasonable and necessary to diagnose and treat an illness or injury. The Insurers required providers to certify that services were medically necessary. In the area of chiropractic care, diagnosis, and treatment, a chiropractor and the hospital where the chiropractor performed procedures, could submit claims for reimbursement to the Insurers, but they were required by law to accurately report the medical condition underlying the claim and only claims that were medically necessary were entitled to reimbursement. D. Manipulation Under Anesthesia 29. Manipulation under anesthesia was a medical procedure allegedly used to treat spinal dysfunction and to restore freedom of movement to extremity joints, such as knees and shoulders. The purported medical rationale for MUA was that fibrotic adhesions (i.e., scar tissues) could form in and around the spine, shoulder, or other extremities, which hindered 5

6 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 6 of 55. PageID #: 6 natural range of motion and caused pain. MU A supposedly broke up these fibrotic tissues through the sudden manipulation of the affected areas, which theoretically increased joint function and reduced pain. 30. Because these adjustments could be extremely painful, patients were put under conscious sedation, known as twilight anesthesia, often through IV administration of the drug propofol, for the entire MUA procedure. 31. MUA was recognized as a surgical procedure by the American Medical Association (the "AMA") and was designated as such in the AMA's Current Procedural Terminology manual. MUA was an aggressive form of therapy and was typically reserved for patients who had failed conservative chiropractic care. 32. There were serious risks of complications associated with MUA, including internal bleeding, unintended tearing of other soft tissue structures, detachment of ligaments and tendons, bone fractures, dislocation of joints, herniation of spinal discs, and spinal cord or neural decompression with resulting paralysis. There were also inherent risks associated with undergoing general anesthesia, namely, aspiration, changes in blood pressure or heart rate, heart attack, stroke, or even death. E. MUA Billing and Codes 33. Due to these risks, including the risks of anesthesia, MUA was not performed in an office setting but rather was typically performed in an outpatient surgical facility, commonly known as an ambulatory surgical center ("ASC"). Consequently, an MUA procedure typically generated three sets of claims to the insurance company: (I) a claim for professional fees; (2) a claim for facility fees submitted by the surgical facility to cover its costs, including supplies associated with the MU A and maintaining a sterile surgical and recovery room; and (3) a claim 6

7 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 7 of 55. PageID #: 7 for anesthesia services, which covered the anesthesiologist's professional services and the anesthesia supplies. 34. The AMA assigned five digit codes to medical procedures performed by health care professionals. The Current Procedural Terminology ("CPT") codes were a listing of descriptive terms for reporting medical services and procedures, providing a uniform language to describe medical, surgical, and diagnostic services. CPT codes provided reliable nationwide communication among physicians, patients, and insurers. All claims to insurers were submitted using CPI codes. The procedures and services represented by the codes were health care benefits, items, and services within the meaning of 18 U.S.C. 24(b). They included codes for office visits, diagnostic testing and evaluation, and other services, based on complexity, severity, and the average time required to perform each service. Health care providers and health care benefit programs were required to use CPT codes to describe and evaluate the services for which they claimed and to decide whether to issue or deny payment. Each health care benefit program established a fee reimbursement for each procedure or service described by a CPT code. 35. Health care facilities submitted a revenue code along with the CPT code when billing for services. Revenue codes were similar to CPT codes in that they represented a certain procedure or service. 36. Health care providers typically used a standard health insurance claim form, or its electronic equivalent, referred to as a CMS-1500 (formerly, HCFA-1500) when submitting claims to insurers. The CMS-1500 required providers to accurately describe the services provided to members using a specific CPI code. Health care facilities claimed reimbursement from insurance carriers on a UB-92 or UB-04 form. On these forms, the provider identified itself by Provider Identification Number ("PIN"), identified the beneficiary who received the services, described the illness or injury that made the services medically necessary, identified the services 7

8 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 8 of 55. PageID #: 8 by revenue code and CPT code, and verified the truth of the claim to the carrier for payment. In response to each claim, the insurance carrier issued payment or denial accompanied by an Explanation of Medical Benefits (the "EOB"). 37. Insurance carriers relied on the representations contained on the claim forms submitted and paid claims based on those representations. Insurers relied upon providers to honestly and accurately describe the services rendered for which payment was sought and the actual charge to the member for providing such service. 38. SHSC and PSG were non-contracted and non-participating providers for the Insurers. As a result, the Insurers reimbursed beneficiaries who obtained services from nonparticipating providers based on formulas specified in their benefit plans. Beneficiaries who chose to see non-participating providers remained responsible for charges above the amount the Insurers paid. Beneficiaries who chose to see non-participating providers typically faced higher out-of-pocket expenses. 39. The Insurers required patients who received services or supplies from SHSC and PSG to satisfy all deductible and co-insurance requirements for out-of-network benefits. A nonparticipating provider could seek reimbursement directly from the Insurers if an individual participant assigned to the provider his or her right to payment on the claim. In that case, the non-participating provider submitted a health service claim form to the Insurers. The Insurers had no way to monitor whether a provider actually collected the required patient responsibility amounts from the member. As such, the Insurers relied on the honesty and integrity of the providers to collect those amounts. A provider's failure to properly reduce the submitted charges or to collect the deductible, co-insurance, or similar amount before submitting a claim was a misrepresentation of the charge. 8

9 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 9 of 55. PageID #: The billing codes associated with the MUA procedure consisted of procedure codes and diagnosis codes. 41. The MUA procedure codes consisted of the following: a Manipulation under anesthesia, shoulder joint. In this procedure, the provider manipulated a patient's shoulder joint with the patient under anesthesia. The provider made no incision. When the patient was appropriately prepped, the provider evaluated the patient and then passively moved or stretched the shoulder joint in the direction of the restricted range of motion. The manipulation consisted of passive movement and stretching of the shoulder joint with an aim to break up the fibrous and scar tissue to relieve pain and improve range of motion. b Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation, with manipulation, requiring more than local anesthesia. The pelvic ring was a ring of bones that connected the tnmk to the legs, also known as the pelvic girdle. Diastasis was the abnormal separation of body parts held together by the muscles. Subluxation was the partial dislocation of a joint. Treatment included manipulation, or adjustment, of the fractured bone. The provider manually adjusted the bones by exerting a pushing or pulling force on the area to bring the pelvis back to normal alignment. After the MUA, the provider may perform an X-ray examination of the pelvic bone to confirm the reduction of the fracture or dislocation. c Manipulation, hip joint, requiring general anesthesia. In this procedure, the provider performed manipulation of the hip joint under anesthesia. Manipulation consisted of passive movement and stretching of the hip joint with an aim to break up the fibrous and scar tissue to relieve pain and improve range of motion. The provider used general anesthesia to reduce pain, spasm, and reflex muscle guarding. The provider was able to break the joint adhesions and soft tissue adhesions, resulting in improved range of motion of the joint. 9

10 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 10 of 55. PageID #: 10 d Manipulation of spine requiring anesthesia, any region. The provider manipulated the spine under general anesthesia to treat spinal dysfunction and to alleviate acute and chronic neck and back pain. The provider made no incision. When the patient was appropriately prepped and anesthetized, the provider manipulated the spine in the area of discomfort. When the provider performed a manipulation of the spine, it encompassed the manipulation performed on the spine, pelvis, and hips. 42. The diagnosis codes, also referred to as the ICD-9 codes, consisted of the following: a Adhesive capsulitis or frozen shoulder. This was a condition characterized by pain and significant loss of both active range of motion and passive range of motion of the shoulder. b Enthesopathy of hip region, e.g., Bursitis of hip Gluteal tendinitis, Iliac crest spur, Psoas tendinitis, Trochanteric tendinitis. Enthesopathies were disorders of peripheral ligamentous or muscular attachments. c Spasm of muscle. d Unspecified Myalgia and myositis, e.g., muscle ache, muscle inflammation not specific to any region. F. Insurer MUA Policies 43. Anthem had a medical policy regarding MU As. MUA was considered medically necessary for only adhesive capsulitis (frozen shoulder) and in the treatment of vertebral fracture, complete dislocation of the spine, or acute traumatic incomplete dislocation (subluxation) of the spine. It was investigational and not medically necessary for all other diagnoses. MUA of any other joint was not medically necessary except for the knee. 10

11 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 11 of 55. PageID #: MM considered MUA (CPT Codes 22505, 23700, 24300, 25259, 26340, and 27860) medically necessary and eligible for reimbursement provided that at least one of the following medical criteria was met: Reduction of acute traumatic cervical facet dislocation; or Shoulder joint adhesive capsulitis (i.e., frozen shoulder) refractory to standard, conventional medical management, including pharmacologic therapy (with or without articular or bursa injections) and physical therapy; or Arthrofibrosis of the knee following trauma or knee surgery (e.g., total knee replacement, anterior cruciate ligament repair); or Chronic extremity contracture(s) refractory to standard, conventional medical management, including failure of, intolerance to or unable to undergo physical therapy including a range of motion exercise program; and at least one of the following clinical conditions, as indicated by ICD-9 diagnosis code, was present: , , , , , , , , 722.0, 723.3, 726.0, , or United had a medical policy regarding MUAs. CPT code (spinal manipulation) was never considered to be proven to be effective treatment and therefore was not a covered service. CPT code (shoulder manipulation) was considered to be proven to be effective treatment and therefore a covered service only for a diagnosis of adhesive capsulitis (otherwise known as frozen shoulder). If that diagnosis was not present, the shoulder manipulation was not a covered service. CPT code (pelvic manipulation, requiring more than local anesthesia) was considered to be effective treatment and therefore a covered service only for a diagnosis of acute traumatic fracture, dislocation, diastasis or subluxation. If those diagnoses were not present, the pelvic manipulation was not a covered service. 46. Aetna had a medical policy regarding MUAs. CPT code (spinal manipulation).was never considered to be proven to be effective treatment and therefore was not 11

12 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 12 of 55. PageID #: 12 a covered service. CPT code (shoulder manipulation) was considered to be proven to be effective treatment and therefore a covered service only for a diagnosis of adhesive capsulitis. Aetna did not provide coverage for CPT codes or II. FACTUAL ALLEGATIONS 47. ED LIV A and CHRIS LIV A formed PSG in Florida and hired MARK FRITZ to handle, among other things, the billing for the professional and facility fees for MUA procedures performed at SHSC. FRITZ was the manager and Chief Financial Officer of PSG, ran the day to day operations, and was involved in providing the guidelines for company procedures. FRITZ was responsible for PSG' s accounting and bookkeeping. 48. To recruit and identify chiropractors to steer patients to SHSC for MUA procedures, CHRIS LIV A partnered with John K., a chiropractor from Northern Ohio, who owned several chiropractic practices and knew many chiropractors in the area. 49. CHRIS LIV A recruited an osteopathic physician, Joseph M., to serve as the "attending" surgeon for the MUA procedure. CHRIS LIV A and MARK FRITZ needed an osteopathic physician, a "D.O.," such as Joseph M., to perform the MU As at SHSC because they wanted to conceal the use of chiropractors, which would cause the Insurers to scrutinize the claims. Joseph M. was paid on a flat-fee basis of$1,500 per day. After Joseph M. stopped performing MU As, SHSC hired Ben 0., M.D., to perform MU As. 50. CHRIS LIV A recruited NICKELS to participate in the scheme by purportedly serving as a "second assist" in the MUA. PSG submitted claims to the Insurers representing that NICKELS was the "co-attending" surgeon for the MUA procedures. CHRIS LIVA paid NICKELS on a flat-fee basis of$1,000 per day, even though NICKELS had a contract with ACA to provide only the anesthesia services during an MUA. At no time did NICKELS actually assist 12

13 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 13 of 55. PageID #: 13 in the MUA procedure itself. And at no time was it ever contemplated that NICKELS would actually assist in the MUA procedure -that was the silent role of the referring chiropractor. A. Marketing to and Training of Chiropractors 51. Beginning in or around 2008, CHRIS LIV A and others known and unknown to the Grand Jury began marketing SHSC and the MUA procedure to chiropractors in Northern Ohio. The marketing meetings typically occurred at restaurants in downtown Cleveland or the Youngstown area. Attendees were invited through a mailing list of chiropractors in the Northern Ohio area. 52. At or around the time of the marketing meetings, CHRIS LIVA and others known and unknown to the Grand Jury entered into oral agreements with chiropractors under which, in exchange for referring their patients to SHSC for MUA, the chiropractors would receive a flat fee of approximately $4,000 for each patient they referred for a three-day session of MU A procedures. Although the majority of chiropractors were paid $4,000 per patient, there were times when a chiropractor was paid $2,000 for a patient receiving something less than the full MU A. FRITZ, ED LIV A, and CHRIS LIV A determined the amount the referring chiropractors were paid. 53. The flat fee was a fixed amount and did not vary based on the degree of involvement by the chiropractor in the MUA procedure. These flat-fee referral agreements induced the chiropractors to refer their patients to SHSC. Although the referring chiropractors would ostensibly assist in performing the actual MUA procedures, these payments were not designed to reimburse the referring chiropractors for services they rendered. Instead, the payments were made to induce referrals of the chiropractors' patients to enable the PSG Entities, SHSC, the ACA Entities to submit inflated charges for professional fees, facility fees, and anesthesia for the MUA procedures. Indeed, a fee of $4,000 for assisting in a brief procedure 13

14 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 14 of 55. PageID #: 14 lasting only a few minutes over three days was significantly more than a chiropractor could ever receive for three chiropractic office visits by a single patient. 54. Before referring a patient to SHSC for the MUA procedure, the chiropractor was required to participate in an MUA "certification course." The certification purported to apply the following national chiropractic standards as set forth by the National Association ofmua Physicians ("NAMUAP") to determine whether the person was an appropriate candidate for the MUA procedure: a. The patient had responded sub-optimally to conservative chiropractic treatment, often with medical co-management, and continued to experience intractable pain or biomechanical dysfunction. b. The patient received sufficient care prior to recommending MUA, usually lasting a minimum period of four to six weeks, but exceptions could apply depending on the patient's individual needs. Manipulation procedures had been used in a clinical setting during this period prior to recommending MUA. c. The patient's level of reproduced pain interfered with activities of daily living or caused disability and the diagnosed conditions fell within the recognized categories of conditions responsive to MUA. d. The patient's treatment of choice was manipulation of the spine or other articulation, however, the patient's pain threshold, injury mechanism, chronicity of the problem, or the fibrous tissue adhesions present, inhibited the effectiveness of conservative manipulation. 55. In contrast to the guidelines purported to apply to chiropractors, the following osteopathic guidelines, which applied to D.O.s like Joseph M., provided that the MUA could be appropriate in cases ofrestrictions and abnormalities of function, including recurrent muscle spasm, range of motion restrictions, persistent pain secondary to injury, and repetitive motion 14

15 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 15 of 55. PageID #: 15 trauma. The osteopathic guidelines also provided that MUA was an alternative approach after the patient's failure to significantly improve with conservative treatment, including but not limited to, osteopathic manipulative treatment ("OMT"), physical therapy, and medication. In general, MUA was limited to patients who had somatic dysfunction, which: a. failed to respond to conservative treatment in the office or hospital that had included the use of OMT, physical therapy, and medication; b. was so severe that muscle relaxant medication, anti-inflammatory medication, or analgesic medications were of little benefit; or c. resulted in biomechanical impairment which could be alleviated with the use of the procedure. 56. Failure may be defined as a lack of significant response in 3-6 weeks in the acute phase, 6-12 weeks in the post-acute phase, and greater than 12 weeks in the chronic phase. In the chronic pain patient, these criteria may be met at the initial evaluation by an osteopathic physician. 57. Under the osteopathic guidelines, MUA was usually a single dose procedure. As with other OMT procedures, patients occasionally reported post-treatment reactions. The reaction could last hours and included musde soreness usually relieved by rest, warm bath, and mild anti-inflammatory or analgesic medication. In some cases, a follow-up MUA could be indicated after a three week interval. If a follow-up MUA was indicated with less than a three week interval, a second opinion was recommended. After a second or follow-up MUA, any additional MUA considerations should be with the consensus of appropriate consultants. 58. One MUA certification course was offered by Robert G. through his company, Cornerstone Professional Education, Inc., ("Cornerstone"), which was sponsored primarily by, and targeted to, chiropractors. Cornerstone marketed and taught MUA certification courses 15

16 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 16 of 55. PageID #: 16 around the country. Robert G.'s MUA course involved a didactic lecture component, typically held at a hotel conference room, with observation and proctorship components that were held at a local ASC. Participants in the course could obtain their certification only after they performed actual MUA procedures on at least one live patient, which the course participant was required to provide. 59. While Robert G. taught his MUA course in several locations, in the fall of2008, Robert G. taught at least one course in Cleveland, Ohio, and used SHSC's facility for the observation and proctorship components. Participants at the course received template language for use in documenting the clinical justification for MUA in their own chiropractic treatment records, sample "letters of medical necessity," and template operative reports for the actual MUA procedure. 60. CHRIS LIV A and others known and unknown to the' Grand Jury told the referring chiropractors that PSG would handle all of the billing for the procedures. Neither PSG nor SHSC provided copies of the MUA operative reports or other procedure records to the referring chiropractors so that they could bill insurers for performing the MUA procedures, either as a coattending provider, otherwise known as a "second assist," or otherwise. 61. CHRIS LIV A and others known and unknown to the Grand Jury explained t? the referring chiropractors that they would only receive their payment after the Insurers paid the professional fees for the MUA procedures, which could often take several weeks or months. PSG paid the chiropractors their referral fees by checks sent through the mail, which were issued by one of the PSG Entities and typically signed by CHRIS LIV A or CAROL VIA. 16

17 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 17 of 55. PageID #: 17 B. Inducements to Patients 62. PSG advised referring chiropractors that patients did not have to pay anything for the procedure. In turn, the referring chiropractors, including SIMONE and FORTUNA, informed their patients that they would not have to pay for the MUA. FRITZ instructed SHSC employees not to take any money from the patients. 63. SHSC paid for the patients' hotel lodging during the three-day MUA procedure as well as the patients' transportation to and from the hotel. C. Insurance Verification for MUA Candidates 64. Employees at SHSC and PSG processed several documents to verify the existence of insurance coverage from the Insurers before they scheduled patients for the MUA procedure. a. SHSC MUA Patient Registration Form. The chiropractors were instructed to execute and fax to PSG an SHSC "MUA Patient Registration Form." The top part of this form, which was to be completed by the referring chiropractor's office, requested information regarding the patient's insurance, including the insurance ID number, group number, phone number, address, and name. The bottom part of this form was to be completed by PSG upon receipt from the chiropractor. The form sought from the insurer the patient's deductible and, among other things, which MUA CPT codes the insurer covered. Written on the form were the numbers 22505, 27194, 23700, and The PSG employee then circled which codes were covered by the insurer. In most cases, the insurer would cover only 27194, 23700, and CPT code was virtually never covered without pre-certification, and therefore, virtually never circled. b. Comprehensive Medical History. Another form the referring chiropractor was instructed to fax to PSG before the MUA could be scheduled was the SHSC 17

18 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 18 of 55. PageID #: 18 "Comprehensive Medical History" form. This form was typically completed by the patient. It did not request the chiropractor's diagnosis. c. Insurance Company Payment Policy. Because the MUA procedure at SHSC was almost always out-of-network for the patients, the patients' insurer routinely sent the payment on the claims submitted by the PSG Entities and the ACA Entities to the patient directly. To ensure payment, the co-conspirators required the patients to sign the Insurance Company Payment Policy form (the "Payment Form"). The Payment Form provided that the patient "affirm[ ed] and attest[ ed] that I am in no way entitled to this reimbursement for medical procedures, and I understand that this money is intended to pay [SHSC, PSG, and others].... [I]n the event I receive a check or checks from the responsible insurance company as payment for my procedure(s) or the insured's procedure(s), I will immediately or within forty eight hours contact the appropriate party (Doctor or Surgical Center) about the check and return these funds to the appropriate party(ies). I understand that I am ultimately responsible for all medical bills if my insurance company fails to pay, and I will assist PSG or any entity with the collection of any funds." d. Referring Chiropractors' notes (referred to as "SOAP notes"). PSG purported to require approximately six to eight weeks of patient care notes from the patient's doctor before approving the patient for MUA. PSG also purported to require notes pertaining to any follow-up care provided by the doctor after the MUA was performed. PSG purportedly instructed the referring chiropractors to or fax their SOAP notes to PSG before the MUA. FRITZ instructed employees at PSG with no medical background to complete pre-approvals based on medical necessity. 65. FRITZ made interstate wire calls from Florida to Ohio to convince the referring chiropractors to add additional codes to their diagnoses in order to obtain insurance coverage. 18

19 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 19 of 55. PageID #: To secure payment for the MUA procedures, PSG employees placed telephone calls to the Insurers using referral forms, supplied by the chiropractors, which listed the patients' name, contact information, and insurance information. PSG's billing staff, which worked from the PSG billing office in Boca Raton under the supervision of PSG employee MARK FRITZ, used the forms to call the Insurers to inquire whether the patients had coverage for certain CPT codes. For example, PSG's billing staff would indicate on these forms whether CPT code (spinal MUA) was covered, and if not, notate that the procedure should not be billed. These worksheets were thus a critical component of the scheme, as they enabled Defendants to bill only procedure codes that were unlikely to trigger further review, and thus conceal the scheme's existence. 67. If the patient's insurance company did not provide coverage for MUA, PSG and SHSC instructed Referring Chiropractors to "continue care as indicated." PSG and SHSC did not permit MU As in the absence of insurance coverage, so Referring Chiropractors did not even discuss the benefits of MU A with patients who might be interested in paying for the procedure with their own money. The scheme focused on obtaining insurance money, not on providing a medical benefit to patients. D. Performance of the MUA Procedure 68. After PSG verified the patient's insurance coverage for the MUA, the patient was scheduled for the three-day MUA procedure at SHSC, typically on a Thursday, Friday, and Saturday. SHSC scheduled the patients on each day in 15-minute increments and could see up to 25 patients in one day. 69. CHRIS LIV A, FRITZ, and others known and unknown to the Grand Jury were sometimes at SHSC on days when the MUA was being performed. On the first morning of the MUA, typically Thursday morning, all of the chiropractors were gathered in the doctors' lounge 19

20 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 20 of 55. PageID #: 20 at SHSC. There, CHRIS LIV A and others known and unknown to the Grand Jury distributed a document referred to as the MUA Fee Routing Slip to the chiropractors. The MUA Fee Routing Slip (hereinafter, the "Fee Routing Slip") was executed by the referring chiropractor at SHSC on the first day of the patient's MUA. The Fee Routing Slip required the chiropractor to provide the patient's name, the chiropractor's name, and the date. The Fee Routing Slip also listed a series of CPT codes, under which were diagnosis codes, descriptions, and boxes for the chiropractor to check. The chiropractors were supposed to sign their names to the Fee Routing Slips after they were executed. An SHSC employee faxed a copy of the Fee Routing Slip to PSG. 70. CHRIS LIV A and others known and unknown to the Grand Jury at times rushed the chiropractors into completing the Fee Routing Slips and instructed the chiropractors to diagnose "pelvic ring fracture." 71. Before receiving anesthesia, Joseph M. interviewed each patient in the company of the referring chiropractor, though Joseph M. did not ask specific questions about prior care. During the interview, Joseph M. executed the following forms: a. The MUA Routing Slip (hereinafter, the "Routing Slip"). The Routing Slip required Joseph M. to list the patient's name, date, doctor (always himself), and "assistant," who he designated as the referring chiropractor. For "Day I" of the MUA, the Routing Slip required Joseph M. to ask the patient about the pain level on a scale of I to 10. The Routing Slip also required Joseph M. to circle on the form the patient's complaint in the categories of cervical spine, thoracic spine, and lumbar spine only. The second page of the Routing Slip contained sections for "Day 2" and "Day 3" of the MUA and required Joseph M. to again ask about the patient's pain level on a scale of I to I 0 and the status of the patient's pain and range of motion. Upon receipt, SHSC Administrator Leslie S. faxed the Routing Slip to Tess D. at PSG. 20

21 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 21 of 55. PageID #: 21 b. The Optimization Letter. Joseph M. also executed a one sentence document that the patient "has been evaluated by me preoperatively, I have reviewed the patient's medical and social history, and the patient is optimized for the planned manipulation under anesthesia." This letter was solely an evaluation of whether the patient could safely be anesthetized. c. The SHSC Patient History and Physical Form (hereinafter, the "History Form"). The History Form listed the patient's name and the procedure that patient was to receive. While there was some variety among the patients' History Forms, namely the patient's medications and allergies, certain sections of the History Form were pre-completed for every patient. Namely, the procedure for every patient was pre-completed as being "Manipulation under anesthesia" and the "history of present illness" for every patient, regardless of actual patient complaints, was "[p]atient complaining of pain to neck, shoulders, arms, back, hips and legs." The History Form was already part of the patients' charts before the MUA procedures. 72. Regardless of the patients' complaints or treatment history, the MUA procedure at SHSC was the same for virtually every single patient: a full, spinal MUA, including the spine, pelvis, and hips; the procedure also typically included manipulation of both shoulders. 73. After Joseph M. interviewed the patient, an anesthesiologist, typically NICKELS, or a nurse anesthetist, Linda P., administered the anesthesia to the patient. Each day of the MUA generated several operating room documents, including the following: a. The SHSC Operating Room Record (hereinafter, the "Op Notes"). The Op Notes indicated the length of time the patient was in the operating room, which for patients receiving the MUA at SHSC was approximately ten minutes or less. The Op Notes listed the "MD/DO," the chiropractor, the anesthesiologist and the CRNA (almost always NICKELS and Linda P., respectively). The Op Notes described the procedures as "Manipulation under 21

22 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 22 of 55. PageID #: 22 Anesthesia" only, without further detail. The Op Notes also required a "Pre Op Diagnosis" and a "Post Op Diagnosis," which evolved over time and in almost every case was completed with the phrase, "chronic pain." b. The MUA Flowsheet (hereinafter, the "Flowsheet"). The Flowsheet provided information such as medications, monitors, and vital signs, but also had a section for "Preop Notes." Occasionally, the "Preop Notes" section would indicate that the patient received a "full spinal MU A." 74. The procedure itself consisted of the D.O., Joseph M., performing the full, spinal MUA while the referring chiropractor assisted. The procedure included manipulating the patient's shoulders, for instance, regardless of whether the patient complained of shoulder pain. The whole procedure, including anesthesia and the manipulation, typically took less than 10 minutes. 75. After the MUA was completed and the anesthesia had worn off, the patient was interviewed, discharged from SHSC, and transported by SHSC to the hotel. In most instances, the patient was not evaluated by the referring chiropractor. In almost every instance, the identical procedure was repeated on the second and third days. E. Insurance Billing 76. The next step in the scheme was for PSG to submit claim forms to the Insurers that would maximize the probability of payment and minimize the detection of their fraud. PSG billed the lnsurers for MUA procedures performed at SHSC on approximately 400 patients. As discussed above, at least the vast majority of these procedures were in fact performed by the referring chiropractors and the osteopathic physician, Joseph M. 77. To maximize the probability of payment and minimize detection of their fraud, Defendants compartmentalized the operational and billing functions: the MUA procedures were 22

23 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 23 of 55. PageID #: 23 performed at SHSC in the Northern District of Ohio, and the billing was performed at PSG, in Boca Raton, Florida. 78. After the MUA procedures, SHSC transmitted via interstate wire from the Northern District of Ohio to PSG in Florida several documents to further document the file. Among the documents sent to PSG were the Fee Routing Slips, the Routing Slips, and the Op Notes. With this information, FRITZ directed the staff at PSG to create the Operation Reports (hereinafter, the "Op Reports"), which were faxed or ed back to SHSC. The Op Reports were created from templates using the Routing Slips that purported to document what happened in the operating room. PSG sometimes sent the Op Reports to the Insurers as well as back to SHSC for entry into the patients' files. 79. Part of the Op Reports' template that virtually never changed from patient to patient was the "Procedures Performed" section and the "Pre-op Diagnosis Section." Virtually every patient's Op Report stated the following: "PROCEDURES PERFORMED: 1. Manipulation under pelvis requiring more than local anesthesia, RIGHT & LEFT 2. Manipulation under anesthesia, shoulder joint, RIGHT & LEFT 3. Manipulation of the spine requiring anesthesia, CERVICAL, THORACIC, & LUMBAR regions. PRE-OP DIAGNOSIS: I. Myalgia and Myositis; cervical, thoracic, lumbar, bilateral shoulder/periscapular musculature, pelvic girdle musculature, and bilateral hip regions (!CD ( 729.1) 2. Spasm of muscle/muscle hypertonicity; cervical thoracic, lumbar, bilateral shoulder/peri-scapular musculature, pelvic girdle musculature, and bilateral pelvic regions (ICD ) 3. Adhesive capsulitis of shoulder (ICD )." 23

24 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 24 of 55. PageID #: The Op Reports contained the D.0.'s name, Joseph M., at the end, providing that Joseph M. "dictated" the Op Report but did not read it, when in truth and in fact, Joseph M. did not dictate the report and never made the diagnoses contained in the Op Report. A separate Op Report was generated for each day the patient received the MUA procedure. 81. FRITZ, CHRIS LIV A, and ED LIV A were responsible for determining what ailment to list in the patients' notes. When PSG employees questioned this practice, they were told to mind their own business. 82. As PSG papered its file, as was customary at all relevant times in this Indictment, PSG used either the electronic equivalent of a standard CMS-1500 (formerly HFCA-1500) health insurance claim form (hereinafter, the "Claim Forms") that required providers to accurately describe the services provided to members using a specific Current Procedural Terminology code (a "CPT Code") or an electronic UB-04 or UB-92 form that required the use of revenue codes for certain facility services. 83. To fraudulently induce the Insurers to provide reimbursement for MU As that were not covered (such as spinal MUA), PSG submitted Claim Forms using CPT or revenue codes that masked and concealed the spinal MUA services actually provided. For example, PSG used codes that described such procedures as "Treatment of Pelvic Ring Fracture or Subluxation," "Manipulation of Hip Joint," and "Fixation of Shoulder" to submit claims for what were, in reality, spinal MUA procedures. 84. For virtually every patient who received the MUA at SHSC, PSG described the patients' diagnosis on the Claim Forms as being the following: for muscle spasms, for adhesive capsulitis, and 729. l for myalgia and myositis. 24

25 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 25 of 55. PageID #: For virtually every patient, PSG billed the Insurers for manipulation of the shoulder under anesthesia using the CPT code 23700, and they did so bilaterally (i.e., both right and left shoulders). PSG also included CPT codes for 27194, and if the Insurer would pay it, On the Claim Forms for professional services, PSG submitted two forms: one Claim Form for the primary doctor performing the MUA and a second Claim Form for the secondary doctor performing the MUA. PSG listed Joseph M., the D.O., as the primary doctor. PSG listed NICKELS, an M.D., on the Claim Forms as the secondary doctor, when they then well knew that NICKELS, the anesthesiologist, administered the anesthesia and did not perform the MUA. At no time did PSG list on the Claim Forms any of the Referring Chiropractors; virtually all Claim Forms instead falsely listed Joseph M. as the "Referring Physician." Defendants then well knew that including only the D.O. and the M.D. on the Claim Forms, and concealing the Referring Chiropractors' roles on the Claim Forms, would maximize the probability of payment and minimize detection of the fraud. 87. The Claim Forms were mailed to or filed electronically with the Insurers. 88. The electronic UB-04 or UB-92 forms for the SHSC facility services were similarly billed using Joseph M.'s name and NPI number only. 89. PSG's bills for the MUA ranged from the tens of thousands to more than one hundred thousand dollars. 90. The ACA Entities billed the insurers for the anesthesia component of the MUA procedure. In turn, the ACA Entities split the proceeds from the MUA procedures performed at SHSC with ED LIVA, CHRIS LIVA, and CAROL VIA through payment to one or more of their entities, including ECSC and E&C. 25

26 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 26 of 55. PageID #: Insurance claims checks were sent directly to the patients because SHSC was outof-network for virtually all the patients' policies. The patients were instructed to endorse the checks and send them to PSG or to their referring chiropractor. PSG took the money from the patient's insurance company, and FRITZ wrote off the rest of the payment to make the patient balance zero paid the referring chiropractors only if PSG was paid by the Insurers. Likewise, PSG paid SHSC only if the Insurers paid PSG. FRITZ and ED LIV A determined the amount the referring chiropractors were paid. CAROL VIA and CHRIS LIVA signed the checks to the chiropractors and were the account holders on all of the PSG bank accounts used in furtherance of the scheme. F. Appeals of Denied Claims 93. If the Insurer denied the claim, then PSG called the insurers to convince them to pay. If that did not work, PSG wrote appeal letters, which sometimes included documentation regarding treatment of the patients. In connection with this process, PSG called the patients to urge them to contact their insurance company, which PSG employees believed would enhance the chance that the Insurers would pay. 94. If the Insurers finally refused payment, FRITZ caused PSG employees to contact the patients and told them to pay and contact their insurance provider, despite assurances to the contrary before the MUA procedures. PSG employees brought collections problems to FRITZ. 95. The ACA Entities also pursued appeals of denied claims for anesthesia related billings. 26

27 Case: 1:14-cr JRA Doc #: 1 Filed: 12/17/14 27 of 55. PageID #: 27 III. STATUTORY VIOLATIONS COUNT! (Conspiracy to Commit Wire Fraud, 18 U.S.C and Health Care Fraud, 18 U.S.C. 1347, in violation of 18 U.S.C. 1349) The Grand Jury charges: 96. The Grand Jury realleges and incorporates b)! reference the allegations set forth in paragraphs 1 through 95 of the Indictment as if fully set forth herein. 97. From in or around December 2007, and continuing until at least approximately September 2010, the exact dates being unknown to the Grand Jury, in the Northern District of Ohio, Eastern Division, and elsewhere, Defendants PSG, CHRISTOPHER LIV A, EDWARD LIV A, MARK FRITZ, JOHN NICKELS, JOHN FORTUNA, and ANTHONY SIMONE did knowingly and intentionally combine, conspire, confederate and agree with each other, and with others both known and unknown to the Grand Jury, to commit federal offenses, to wit: a. To knowingly and willfully execute and attempt to execute a scheme and artifice to defraud a health care benefit program, and to obtain, by means of false and fraudulent pretenses, representations and promises, money owned by, and under the custody and control of, a health care benefit program, namely, the Insurers, in connection with the delivery of or payment for health care benefits, items and services, in violation of Title 18, United States Code, Section (Health Care Fraud); and b. To devise and intend to devise a scheme and artifice to defraud the Insurers, and to obtain money from the Insurers by means of false and fraudulent pretenses, representations and promises, and for the purpose of executing such scheme and artifice, to transmit and cause the transmission by means of wire communications in interstate commerce any writing, sign, signal, and picture, in violation of Title 18, United States Code, Section 1343 (Wire Fraud). 27