MEDICAID FRAUD REPORT

Transcription

1 MEDICAID FRAUD REPORT National Association of Medicaid Fraud Control Units January/February 2012 INSIDE Lead Article... 1 Cases... 2 New York MFCU Announces Prison Sentence for Woman Who Forged More Than 250 Painkiller Prescriptions Attorney General Eric T. Schneiderman announced on February 16 that prison time was secured for the ringleader of an illegal prescription drug operation who forged more than 250 prescriptions for narcotics, including addictive painkillers like OxyContin and Roxicodone. Suzanne Benizio, who pleaded guilty to two counts of forgery in the second degree in December 2011, will receive consecutive sentences totaling four to eight years in state prison. In addition to incarceration, Benizio will be ordered to repay the New York State Medicaid program over $200,000. In order to prevent crimes like these from happening in the future, Attorney General Schneiderman has proposed a plan to rein in the state s prescription drug epidemic. Schneiderman s Internet System for Tracking Overprescribing (I-STOP) legislation connects doctors and pharmacists to a real-time, online database that tracks the prescribing and dispensing of frequently abused controlled substances. Had I-STOP been in place, it would have invalidated Benizio s forged prescriptions and prevented this supply of addictive painkillers from reaching communities across the state. Between 2009 and 2011, Benizio created more than 250 forged prescriptions for OxyContin and Roxicodone, both strong painkillers. She wrote the prescriptions by hand, or created them using a computer, on prescription paper stolen from doctors and hospitals in the New York City area. At the time of her arrest in March, Benizio possessed enough prescription paper to create an additional 1,500 prescriptions. She also possessed a special printer needed to process the thermal prescription paper the state uses as a security measure. The scope and reach of Benizio s profit-making operation was significant. As the ringleader, she worked with multiple co-conspirators to create prescriptions in the names of real Medicaid recipients. Working with another group of co-conspirators, she then arranged for the forged prescriptions to be filled at pharmacies throughout the state. The Attorney General s Medicaid Fraud Control Unit identified and tracked these forgeries to pharmacies in 20 different counties.

2 Not only did Benizio flood the state with more than 20,000 frequently-abused substances, she paid for them with taxpayer money. Benizio misappropriated numerous Medicaid cards that were then used to create the forged prescriptions. The cards were subsequently presented to the pharmacies that filled the prescriptions. All told, the New York State Medicaid program paid more than $200,000 to fill the prescriptions in question. The ISTOP system requires doctors, prior to prescribing certain controlled substances, to check a database to ensure that the prescription is medically necessary and not simply an effort to access narcotics. Pharmacists are then required to check the database and confirm that prescriptions were made to the patient for those controlled substances to prevent the filling of forged or ill-gotten prescriptions. According to the federal Office of National Drug Control Policy, prescription drug abuse is the country s second most prevalent illegal drug problem. New York State ranks 11th in the nation for admissions to chemical dependence programs for abuse of opioids other than heroin. At the same time, prescriptions for oxycodone have increased an astonishing 82 percent since For further information contact Special Assistant Attorney General Jacob Bergman or Senior Special Investigator Thomas Dowd (212) CASES Counselors: Tennessee The Tennessee Medicaid Fraud Control Unit announced on May 27, 2011 that Gregory Motley, owner of a counseling service and licensed Master Social Worker, entered a plea of guilty to one count of TennCare fraud. Motley was sentenced to eight years incarceration but ordered to serve nine months on the weekends before serving his alternative sentence of nine years probation. He was ordered to pay restitution in the amount of $49, to the State of Tennessee. This case was opened on September 11, 2008, based on a referral from the Tennessee Office of Inspector General. The referral indicated that Motley was utilizing unlicensed counselors to bill for mental health services and billing for services that were not rendered. Motley was indicted on September 16, 2010 on one count of TennCare fraud. For further information contact Special Agent Terry Reed (901) Counselors: Texas Attorney General Abbott announced on February 23 that licensed professional counselor (LPC) Margie E. Hollingsworth pleaded guilty in federal court to false statements in a health care matter. Hollingsworth was indicted for billing for counseling services she allegedly did not provide. 2

3 Investigators determined that she was living in Colorado and doing her counseling by phone to patients throughout Texas. The Medicaid overpayment is more than $565,000. Attorney General Abbott announced on February 29 that clinic operator Kevin Jerome Johnson was sentenced to four years incarceration and was ordered to pay $25,000 in restitution after pleading guilty in state court to theft. Johnson and five others were indicted for engaging in organized criminal activity for allegedly billing Medicaid and Medicare for psychological counseling and physical therapy services that were not provided. The fraud is approximately $4.3 million. For further information on both cases contact Rick Copeland, Director or Chief Investigator Travis Tucker (512) Dental Centers: New York Attorney General Schneiderman announced on January 9 that Baker Victory Health Services Dental Center has paid the state $325,000 in restitution to resolve a Medicaid fraud case involving excess payments received on claims for dental services. An audit-investigation conducted by the Medicaid Fraud Control Unit revealed that during the period of January 1, 2005 though December 31, 2009, Baker Victory submitted and received payments for dental clinic services for which Medicaid reimbursements were not authorized. The audit-investigation determined that in addition to performing unnecessary procedures, the clinic performed procedures that should have been done in one visit over multiple visits, resulting in additional fraudulent reimbursements. Medicaid regulations authorize reimbursements only for teeth cleanings performed every six months, barring medical necessity. In some cases, Baker Victory patients were receiving cleanings every three to four months without such medical necessity at the taxpayers expense. In other cases in violation of Medicaid regulations that required Baker Victory to perform and bill for cleanings, X -rays, and dental exams in one office visit the Center performed such procedures over separate visits, thereby enabling it to collect more money from the Medicaid program. For further information contact Gary Baldauf, Regional Director, Buffao or Supervising Special Auditor-Investigator Raymond August (716) Drug Diversion: Tennessee The Tennessee Medicaid Fraud Control Unit announced on June 2, 2011 that Roger William Catlin, MD, was given post trial diversion after pleading guilty to two counts of feloniously dispensing or distributing controlled drugs. Catlin was sentenced to two years of probation. 3

4 This case was opened on May 29, 2009, based on a referral from the Health Related Boards. It was alleged that Catlin was writing prescriptions for one of his employees using various forms of the name and date of birth. The employee would then return some of the filled prescriptions to him. Catlin entered into a post trial diversion on June 2, The Tennessee Medicaid Fraud Control Unit announced on April 18, 2011 that Regina Bowman, an X-Ray technician, was given deferred judgment after pleading guilty to three counts of obtaining controlled substance by fraud. Bowman was sentenced to six years probation. This case was opened on May 29, 2009, based on a referral from the Health Related Boards. It was alleged that Bowman was receiving numerous prescriptions from a physician where she worked in various names and dates of birth. Bowman would then return many of the filled prescriptions to the physician. On May 24, 2010, Regina Bowman was indicted on eleven counts of obtaining a controlled substance by fraud. For further information on both cases contact Special Agent Kim Harmon (615) Durable Medical Equipment: Georgia Attorney General Samuel Olens announced on January 12 that Eddie Leon Castleberry was sentenced to prison for Medicaid fraud. Castleberry entered a plea of guilty to one count of Medicaid fraud. Castleberry was the owner of Castle Medical Services, a durable medical equipment company. During the time period from May 10, 2007 to June 16, 2010, Castleberry repeated billed the Georgia Medicaid program for durable medical equipment and diabetic supplies that were never delivered to the recipients. Once he obtained the Medicaid number of a recipient requiring a piece of equipment, Castleberry billed that person s number for numerous pieces of equipment not ordered by the physician and not delivered to the patient. Castleberry was sentenced to two years in prison followed by eight years on probation. He was ordered to pay $120,000 in restitution to the Georgia Department of Community Health, the agency that administers the Georgia Medicaid program. For further information contact Senior Assistant Attorney General Nancy Allstrom (770) , ext Durable Medical Equipment: Nevada Attorney General Catherine Cortez Masto announced on February 3 that DeAngelo Henderson was sentenced to 12 to 48 months in prison and ordered to repay $336,000 in restitution, penalties, and costs in a Medicaid fraud case involving Golden Heart Medical Supply (Golden Heart). 4

5 Medicaid provides payment to furnish medical supplies that allow people to care for their own medical conditions, gain mobility and maintain hygiene. In January 2009, Nevada Medicaid provided information to the Attorney General s Office that Golden Heart, a medical equipment company operating in Henderson s name, had submitted and been paid an unusually high amount of Medicaid claims. Further investigation by the office revealed that Golden Heart s purported clients did not receive supplies from Golden Heart and were actually clients of other companies. Attorney General investigators discovered that Henderson, through Golden Heart, submitted false claims to Medicaid claiming Golden Heart provided medical supplies to non-existent clients and received payment for these claims. Henderson pleaded guilty to a felony offense of submission of false Medicaid claims. For further information contact Deputy Attorney General Matthew Jensen (775) Durable Medical Equipment: Tennessee The Tennessee Medicaid Fraud Control Unit announced on May 17, 2011, that Michael E. Cohen, owner of Stat Diagnostic, was sentenced in the United States District Court for the Western District of Tennessee after pleading guilty to defrauding Medicare and Medicaid. Cohen was sentenced to six months with the United States Bureau of Prisons, and upon release will be placed on supervised probation for three years. Among other additional conditions of supervised release he will participate in the home detention program for a period of 18 months. Additionally, Cohen was ordered to pay restitution of $630, to CMS and $18, to TennCare. This case was opened on August 3, 2009, based on a referral from the United States Attorney s Office in the Western District of Tennessee. It was alleged that Cohen s business, Stat Diagnostic, was soliciting/telemarketing Medicare patients, up-coding, billing for devices that were never delivered to the patient and billing and providing medically unnecessary products. It was also alleged that they did not have licensed and certified fitters that went to the patients home to fit them for their diabetic shoes and/or inserts. For further information contact Special Agent Alaina Kring (901) Durable Medical Equipment: Texas Attorney General Abbott announced on January 24 that Okey Fetus Nwagbara, owner of Advanced Medequip & Supplies, Ltd., pleaded guilty in federal court to conspiracy to commit health care fraud, providing a false statement on immigration documents, and unlawful procurement of naturalization. Sentencing is pending. Nwagbara allegedly conspired to bill Medicare and Medicaid for enteral nutrition services not medically necessary. Attorney General Abbott announced on January 30 that Aghaebono "Ike" Odelugo was sentenced in federal court to 72 months of incarceration with three years supervised release and was ordered to pay $11,133 restitution to Medicaid and $9,933,354 to Medicare. Odelugo pleaded 5

6 guilty in August 2010 to conspiracy, healthcare fraud, and money laundering. Spectrum Foundation, a DME company, is owned by Emeka Orji. Orji was allegedly used as a front by Odelugo, who actually ran the company. Odelugo and Orji billed Medicaid and Medicare for services allegedly not provided. Odelugo is pending sentencing in state court for health care related theft charges. Attorney General Abbott announced on February 1 that Francis Joseph Ibiok pleaded guilty in federal court to conspiracy to commit health care fraud and illegal remuneration. Ibiok, owner of By The Grace Medical DME, allegedly billed for DME products not delivered. He and Shavator Shakun Albro allegedly conspired to use a closed DME company, Expediate Healthcare Supply, LLC, to bill Medicaid for incontinent supplies that were not provided. A third defendant allegedly supplied Medicaid and Medicare recipient identification information to Albro and Ibiok. Albro pleaded guilty in August 2011 to conspiracy to commit health care fraud and illegal remuneration. Attorney General Abbott announced on February 6 that Felicitas Alanis and Erika Ortega Alanis pleaded guilty in federal court to conspiracy to commit health care fraud. Alanis, owner of Vel -Ala, Inc., d/b/a Nisi Medical Supplies, and biller Alanis allegedly billed for more products than were delivered. The alleged Medicaid fraud is over $573,000. Attorney General Abbott announced on February 6 that Arthur Johnson pleaded guilty in state court to theft. Johnson and his spouse own TOPS Medical Supply. They were indicted in March 2011 for felony theft for billing Medicaid for incontinence supplies allegedly not delivered. The identified fraud is approximately $160,000. Attorney General Abbott announced on February 21 that Lodrick Chukwudi Eneh was sentenced in federal court to two years incarceration with three years supervision and was ordered to be turned over to immigration authorities upon completion of his sentence. Eneh pled guilty in June 2011 to federal illegal remunerations charges. Eneh allegedly solicited Medicare beneficiary information and received kickback payments for referring beneficiary information to coconspirators. Of the nine co-conspirators in the case, one is an indicted fugitive and all others have now been convicted and sentenced. The case involves Jasper Amadi Ogbonna, owner of Matrix Medical Equipment & Supply (Matrix), in a scheme to bill for durable medical equipment that was allegedly never properly prescribed by a physician. Matrix was paid approximately $845,000 by Medicare but all Medicaid claims were denied. 6

7 Attorney General Abbott announced on February 24 that a federal jury convicted Michelle Turner of conspiracy to commit health care fraud, conspiracy to receive kickbacks, and receipt of kickbacks. On February 22, Rolandae Straughter was sentenced to 18 months in prison followed by three years of supervised release and was ordered to pay $501, in restitution to Medicare. Straughter pleaded guilty in March 2010 to conspiracy to commit health care fraud for allegedly taking kickbacks for providing beneficiary information to Family Healthcare Services. Ana Quinteros was sentenced on February 9 to three years probation and was ordered to pay $122, in restitution. These defendants are three of six subjects associated with Family Healthcare Services, indicted in an alleged scheme to bill the accounts of Medicare beneficiaries for orthotic kits which they did not receive. Some beneficiaries allegedly received cheap substitute neoprene braces and/or received total orthotic kits that were not medically necessary. Owners Princewill Njoku and Clifford Ubani previously pleaded guilty to conspiracy to commit health care fraud. Family Healthcare Services was paid $465,000 by Medicare, all of which was identified as an overpayment. Attorney General Abbott announced on February 24 that Rose Essien was sentenced to 60 months in prison followed by two years supervised release and was ordered to pay $1,455, in restitution. She was convicted in April 2011 of multiple counts of health care fraud and aggravated identity theft. On February 9, her father, Bassey Essien, was sentenced in federal court to 99 months in prison followed by three years of supervised release and was ordered to pay $1,455, in restitution. Essien was convicted at trial in April 2011 of conspiracy, health care fraud, and aggravated identity theft. Benjamin Essien, Rose Essien s brother, was sentenced in December 2011 to 145 months in prison and was ordered to pay $1,455, restitution. The defendants were part of two companies, Logic World Medical Supply and Roben Medical Supplies, that allegedly billed Medicaid for incontinence supplies that were not delivered or only partially delivered. The identified overpayment is approximately $1.2 million. For further information on these cases contact Rick Copeland, Director or Chief Investigator Travis Tucker (512) Hearing Aides: Texas Attorney General Abbott announced on January 13 that Debra Spradlin was sentenced in federal court to 10 years of incarceration and was ordered to pay $1.6 million in restitution. Spradlin pleaded guilty to conspiracy to commit healthcare fraud in January Spradlin and her deceased husband, Michael Wayne Spradlin, co-owned Central Texas Hearing. Michael Spradlin was a hearing aid fitter and distributor and Debra Spradlin, a company biller. The Spradlin's were paid for hearing aids and services that allegedly were not delivered. The suspected fraud is over $1.5 million. 7

8 For further information cases contact Rick Copeland, Director or Chief Investigator Travis Tucker (512) Home Health Care: Idaho Attorney General Lawrence Wasden announced on January 31 that Terry L. Leissring, a Medicaid provider, was sentenced for grand theft by submitting false claims to Medicaid. Leissring was sentenced to two to ten years in prison. The court retained jurisdiction for 365 days and ordered Leissring into immediate custody. Restitution will be determined at a later date. In 2006, Leissring signed an agreement with the Idaho Medicaid Program to provide service coordination services. On the agreement, she noted that she was the owner and administrator of Brighter Days, Inc. and a paraprofessional. She also listed professional service coordinators who would supervise the services for Brighter Days. An investigation by the Idaho Attorney General s Medicaid Fraud Control Unit revealed that she did not have the required college degree to provide any of the services she provided; she did not have the required supervision professionals on staff as she claimed; she received $39, for services she did not provide to her clients; she did not meet with the families involved to provide the services in question; and she told investigators she had professionals supervising her work, when this was not the case. The victims either went without health care services or there was a delay until the families could locate the services themselves. In two cases, mothers with a child with profound needs were left to fend for themselves in finding services for their child while Leissring billed Medicaid for the services she claimed she was providing. In one of these cases, the mother had a three-year-old child with brain damage from lack of oxygen, cerebral palsy, blindness, a seizure disorder, a sleep disorder, acid reflux syndrome and a feeding tube. The child was on 16 medications, had seven doctors, physical and occupational therapists and a speech therapist. Leissring left this mother to coordinate all the health care providers, find funding for needed equipment and pursue educational opportunities for her child, while Leissring submitted claims to Medicaid for work Leissring never provided. Service coordination is designed to help those eligible for Medicaid in gaining and coordinating access to necessary and appropriate care and services. Service coordination is required to be performed by a person with at least a bachelor s degree in a human services field or a licensed professional nurse. Leissring did not have the required bachelor s degree. Instead, she had a high school diploma, an art certificate from an art instruction school and a travel and touring certificate from a travel school. The investigation was initiated by a referral from the Medicaid Program Integrity Unit with the Idaho Department of Health and Welfare s Bureau of Audits and Investigations. 8

9 For further information contact Prosecutor Mark Hiedeman (208) Home Health Care: Ohio Attorney General DeWine announced on January 9 that Delerisa Blank pleaded guilty to one count of falsification in a theft offense, a felony of the fourth degree, and was sentenced to five years of community control, ordered to pay court costs in an amount to be determined, and ordered to pay restitution in the amount of $8, If the defendant violates community control she will receive a one year prison term. On November 15, 2011, a bill of information was filed charging Blank with one count of falsification in a Theft Offense, a felony of the fourth degree. Blank, an independent provider, billed for services not rendered. For further information contact Assistant Attorney General Daniel Huston (614) Attorney General Dewine announced on January 10 that Jennifer Mahaney pleaded guilty to one count of theft, a misdemeanor of the first degree and was sentenced to a 180 day suspended jail sentence, one year probation, and ordered to pay restitution in the amount of $1, On October 18, 2011, an indictment was filed charging Mahaney with one count of theft by deception, a felony of the fifth degree. Mahaney, an independent provider, billed for services not rendered. For further information contact Assistant Attorney General Shawn Napier (614) Attorney General DeWine announced on January 23 that Laura Rogers pleaded guilty to one count of theft, a misdemeanor of the first degree, and was sentenced to a 120 day suspended jail sentence, ordered to pay court costs in an amount to be determined, and ordered to pay restitution in the amount of $1, to ODJFS and $ to Cambridge Home Health Care, Inc. On August 16, 2011, an indictment was filed charging Rogers with one count of theft, a felony of the fifth degree, and one count of forgery, a felony of the fifth degree. Rogers, an independent provider, billed for services not rendered. For further information contact Assistant Attorney General Daniel Huston (614) Attorney General DeWine announced on January 25 that Nancy Conkle pleaded guilty to one count of theft, a misdemeanor of the first degree and was sentenced to a 100 day suspended jail sentence, three month probation, and ordered to pay restitution in the amount of $1, Conkle, an independent provider, billed for services not rendered. On November 15, 2011, an 9

10 indictment was filed charging Conkle with one count of theft, a felony of the fifth degree. For further information contact Assistant Attorney General William Greene (614) Attorney General DeWine announced on January 27 that Cheryl Lukehart was sentenced to three years of community control, ordered to pay court costs in an amount to be determined, and ordered to pay restitution in the amount of $10,000. If the defendant violates community control she will receive a prison term of 12 months. On February 15, 2011, an indictment was filed charging Lukehart with one count of theft, a felony of the fourth degree. On November 30, 2011, Lukehart pleaded guilty to one count of theft, a felony of the fifth degree. Lukehart, an independent provider, billed for services that were never provided For further information contact Assistant Attorney General Constance Nearhood (614) 466- Attorney General DeWine announced on January 30 that Anna Freas-Deck pleaded guilty to one count of theft, a misdemeanor of the first degree and was sentenced to pay court costs in an amount to be determined, and pay restitution in the amount of $ On January 5, a complaint was filed charging Freas-Deck with one count of theft, a misdemeanor of the first degree. Freas- Deck, an independent provider, billed for services not rendered. Attorney General DeWine announced on January 30 that Nancy Molden pleaded guilty to one count of theft, a misdemeanor of the first degree and was sentenced to pay court costs in an amount to be determined, and to pay restitution in the amount of $ On January 5 a complaint was filed charging Molden with one count of theft, a misdemeanor of the first degree. Molden, an independent provider billed for services not rendered. For further information on both cases contact Assistant Attorney General William Greene (614) Attorney General DeWine announced on February 8 that Allison Brandenburg-Dynes pleaded guilty to one count of attempted falsification in a theft offense, a felony of the fifth degree and was sentenced to one year of community control, and ordered to pay restitution in the amount of $20,000. On August 16, 2011, an indictment was filed charging Brandenburg-Dynes with one count of grand theft, a felony of the fourth degree, and one count of falsification in a theft offense, a felony of the fourth degree. Brandenburg-Dynes, an independent provider, billed for services not 10

11 rendered to two recipients. For further information contact Assistant Attorney General Dan Huston (614) Attorney General DeWine announced on February 28 that Theresa Williams pleaded guilty to one count of theft by deception, a misdemeanor of the first degree and was sentenced to 21 days in jail, ordered to pay a $100 fine, pay court costs in an amount to be determined, and ordered to pay restitution in the amount of $1,356. If fine and court costs are paid within 90 days the 21 day jail sentence will be suspended. On August 17, 2011, an indictment was filed charging Williams with one count of theft by deception, a felony of the fifth degree. Williams, an independent provider, billed for services not rendered. For further information contact Assistant Attorney General Shawn Napier (614) Home Health Care: Tennessee The Tennessee Medicaid Fraud Control Unit announced on July 21, 2011 that Lee Thelma Jones, a business owner, pleaded guilty to four counts of healthcare Fraud. Jones was sentenced to three years of probation and six months of home detention. Jones was ordered to pay restitution of $720, and a special assessment of $400. This case was opened on March 18, 2008, based on a referral from the U. S. Department of Health and Human Services Office of Inspector General. It was alleged that Jones owner of J. Blackwell & Associates was billing elderly and disabled patients for psychotherapy and home medical visits while providing only homemaker social services. Jones was fraudulently billing the Medicare program and attempted to bill the Medicaid program for psychotherapy services that were not provided. Jones billed these services under a physician s number without his knowledge. For further information contact Special Agent Angel Beverly (615) The Tennessee Medicaid Fraud Control Unit announced on August 10, 2011 that Vickie Campbell, LPN, pleaded guilty to one count of TennCare fraud. Johnson was sentenced to two of years incarceration but was given an alternative sentence of two years of probation. This case was opened on April 24, 2008, based on a referral from the owner of a home health agency. It was alleged that Campbell was charting a patient as if she was seeing the patient in their home but was not going. Campbell was submitting false claims and being paid for the time she did not spend with the patient. 11

12 The Tennessee Medicaid Fraud Control Unit announced on August 10, 2011 that Christin Johnson, LPN, pleaded guilty to one count of TennCare fraud. Johnson was sentenced to 11 months 29 days incarceration but was given an alternative sentence of 11 months 29 days probation. This case was opened on April 24, 2008, based on a referral from the owner of a home health agency. It was alleged that Johnson was falsifying patient records by claiming to have seen patients when she did not. Johnson would pay other individuals along with family members of the patients to take care of them and then turn in the time as if she was providing care to the patients. The Tennessee Medicaid Fraud Control Unit announced on August 10, 2011 that Amanda L. Stinnett, LPN, pleaded guilty to one count of TennCare Fraud. Stinnett was sentenced to two years incarceration but was given an alternative sentence of two years probation. This case was opened on April 24, 2008, based on a referral from the owner of a home health agency. It was alleged that Stinnett was billing for services not rendered. Stinnett would turn in time sheets and nurses notes corresponding with dates and times she said she saw these patients. Stinnett would pay family members to take care of the patients and then chart as if she was taking care of them For further information on these cases contact Special Agent Darrin Shockey (931) 261- The Tennessee Medicaid Fraud Control Unit announced on August 24, 2011 that Glenesha Bowling-Moye, a business owner, pleaded guilty to one count of conspiracy to commit healthcare fraud, two counts health care fraud and two counts money laundering. Bowling-Moye was sentenced to 18 months of incarceration and two years of probation. Bowling-Moye was ordered to pay restitution of $661, and special assessment of $500. This case was opened on April 27, 2007, based on a referral from the U. S. Department of Health and Human Services Office of Inspector General. It was alleged that Bowling-Moye and her business partner were billing for services they did not render. Jones and her business partner operated a home health agency where elderly patients were billed for medical and psychiatric services they did not receive. 12

13 The Tennessee Medicaid Fraud Control Unit announced on August 24, 2011 that Tabitha Jones, a business owner, pleaded guilty to one count of conspiracy to commit healthcare fraud, one count of health care fraud and one count of money laundering. Jones was sentenced to one year and one day of incarceration and two years of probation. Jones was ordered to pay restitution of $583, and a special assessment of $300. This case was opened on April 27, 2007, based on a referral from the U. S. Department of Health and Human Services Office of Inspector General. It was alleged that Jones and her business partner were billing for services they did not render. Jones and her business partner operated a home health agency where elderly patients were billed for medical and psychiatric services they did not receive. The Tennessee Medicaid Fraud Control Unit announced on September 9, 2011 that Regina Noll Males was given judicial diversion after entering a best interest plea to one count of Theft over $1,000. Males was sentenced to two years of probation and ordered to pay restitution of $2,500 to Habilitation and Training Service, Inc. This case was opened on July 19, 2011, based on a referral from the Department of Intellectual and Developmental Disabilities. It was alleged that Bryan Males, an employee of Habilitation and Training Service, Inc., was submitting claims for payment for services not rendered. Upon investigation, it was discovered that Regina Males, his spouse, was responsible for the fraudulent claims, without his knowledge For further information on these cases contact Special Agent Robert Simmons (615) 744 Home Health Care: Texas Attorney General Abbott announced on January 25 that Adlema Sevilla was sentenced in federal court to 18 months in prison followed by 36 months of supervised release and was ordered to pay $336,000 in restitution. Sevilla pleaded guilty in April 2011 to conspiracy to commit health care fraud. On January 10, 2010, Sammie Wilson was sentenced in federal court to three years of probation, the first six months of which will be home confinement and was ordered to pay $56, in restitution. Wilson pleaded guilty in October 2010 in federal court to kickback violations and conspiracy to commit health care fraud. Sevilla, Wilson and nine others were indicted and have either pleaded guilty to or were convicted at trial of multiple counts of conspiracy, health care fraud, paying or receiving kickbacks, and making false statements. Princewill Njoku, Clifford Ubani and their respective wives, Caroline and Ezinne, allegedly orchestrated a scheme to pay home health nurses and marketers for the admission and subsequent re-certification of home healthcare patients. Sevilla 13

14 was a nurse accused of falsifying home health certification forms. Wilson was a beneficiary/ marketer who purportedly accepted kickbacks who return for accepting home health services which were not rendered. The identified fraud amount is approximately $5.1 million. Attorney General Abbott announced on February 3 that care giver Gwendolyn Alexander and Medicaid recipient Joe Ann Haven were indicted by a state grand jury for aggregate theft. Alexander, care giver for Agape Home Healthcare, and Haven allegedly conspired to submit fraudulent claims for personal assistant services when recipient Haven was either hospitalized or in jail and not eligible for Medicaid. Attorney General Abbott announced on February 14 that Mary Ellis was sentenced in federal court in Houston to 63 months in prison followed by three years of supervised release and was ordered to pay restitution of $401,000. Eleven subjects in this case were indicted and ten have either pleaded guilty to or were convicted at trial of multiple counts of conspiracy, health care fraud, paying or receiving kickbacks, and making false statements. Six have been sentenced and four are awaiting sentencing. The losses to Medicaid and Medicare associated with this case are estimated to be $5.1 million. Princewill Njoku, Clifford Ubani and their respective wives, Caroline and Ezinne, allegedly orchestrated a scheme to pay home health nurses and marketers for the admission and subsequent re-certification of home healthcare patients. Mary Ellis was an LVN who allegedly accepted kickbacks for the referral of beneficiaries. Adlema Sevilla and Cynthia Garza Williams were nurses accused of falsifying home health certification forms. Terrie Porter, Florida Holiday Island, and Margaret Pleasant allegedly recruited patients and were paid kickbacks. Sammie Wilson was a beneficiary/marketer who purportedly accepted kickbacks in return for accepting home health services which were not rendered Princewill Njoku and Clifford Ubani pleaded guilty. Caroline Njoku was convicted at trial and on February 13 was sentenced to 63 months in prison followed by one year of supervised release and was ordered to pay restitution of $631,295. Ezinne Ubani was convicted at trial. Sevilla pleaded guilty and was sentenced on January 25 to 18 months in prison and was ordered to pay $336,000 in restitution. Williams pleaded guilty. Porter was convicted at trial and on February 13 was sentenced to 24 months in prison followed by two years of supervised release and was ordered to pay restitution of $482,380. Island pleaded guilty and on February 13 was sentenced to 20 days in prison and five months of home detention followed by 30 months of supervised release and was ordered to pay restitution of $59,739. The prosecution of Pleasant is still pending. Wilson pleaded guilty and was sentenced on January 10 to three years of probation, the first six months of which served as home confinement and was ordered to pay $56, in restitution. 14

15 For further information on these cases contact Rick Copeland, Director or Chief Investigator Travis Tucker (512) Home Health Care Aides: Ohio Attorney General DeWine announced on January 12 that Maurice Walker was sentenced to three years of community control, serve 30 days in the county corrections center, pays a fine of $250 and in court costs in an amount to be determined, and ordered to pay restitution in the amount of $19, If the defendant violates community control he will receive a prison term of 17 months. On June 21, 2011, an indictment was filed charging Walker with one count of grand theft, a felony of the fourth degree, and one count of falsification in a theft offense, a felony of the fourth degree. On November 10, 2011, Walker pleaded guilty to one count of grand theft, a felony of the fourth degree. Walker, a home health care aide, billed for services not rendered and paid a kickback to the recipient. For further information contact Assistant Attorney General Constance Nearhood (614) Attorney General DeWine announced on January 30 that Leonte Knowles pleaded guilty to one count of theft by deception, a misdemeanor of the first degree and was sentenced to five years of community control, a 180 day suspended jail sentence, and ordered to pay restitution in the amount of $42, On May 17, 2011, an indictment was filed charging Knowles with one count of theft by deception, a felony of the fourth degree. Knowles, a home health care aide, for Medsource Home Care billed for services not rendered. Attorney General DeWine announced on February 14 that Sharde Roberts pleaded guilty to one count of theft by deception, a misdemeanor of the first degree and was sentenced to ten days in the county corrections center, and ordered to pay restitution in the amount of $1,300. On September 20, 2011 an indictment was filed charging Roberts with one count of theft by deception, a felony of the fifth degree. Roberts, a home health care aide, billed for services not rendered. For further information on both cases contact Assistant Attorney General Shawn Napier (614)

16 Hospitals: Texas Attorney General Abbott announced on February 22 that Mohammad Kahn pleaded guilty in federal court to conspiracy to commit health care fraud, conspiracy to pay health care kickbacks and to paying health care kickbacks. Kahn was the CEO of Riverside General Hospital, a longstanding facility. Kahn, through the hospital, operated approximately ten Community Mental Health Centers (CMHC) which, in turn, each administered a Partial Hospitalization Program (PHP) and each submitted billing under the hospital s billing number. It was alleged that many of the PHP participants did not meet the eligibility criteria for the program s services. For further information contact Rick Copeland, Director or Chief Investigator Travis Tucker (512) Medical Centers: New York Attorney General Schneiderman announced on January 25 a settlement with Cayuga Medical Center (CMC) for violating the Stark Act, which prohibits a physician from referring patients to a hospital if the physician has a financial relationship with the hospital, unless an exception applies. In addition, the Stark law also prohibits a hospital from billing Medicaid for a prohibited referral. Working with the U.S. Attorney s office for the Northern District of New York, the entire settlement totals $3,149, for both Medicare and Medicaid damages. The total Medicaid recovery is $710,508, and New York will receive $426,305. CMC itself disclosed that certain recruitment agreements with physicians did not comply with the Stark Act. The whistleblower, or qui tam, lawsuit was filed by Dr. Daniel Jorgenson a plastic surgeon with admitting privileges at Cayuga Medical Center, in 2007 outlining two questionable recruitment agreements with the hospital that violated the Stark Act. As a whistleblower, Dr. Jorgenson will receive 18 percent of the settlement proceeds. For further information contact Jay Speers, Counsel to the New York Medicaid Fraud Control Unit, (212) or Civil Enforcement Chief Auditor Michael LaCasse (315) Medical Equipment: Texas Attorney General Abbott announced on January 23 that Prince Namadi Oji pleaded guilty in federal court to an information charging money laundering of proceeds obtained through conspiracy to commit health care fraud and mail fraud. Oji owned Florida Blvd Medical Equipment & Supply. Oji allegedly bought and sold patient records and used those identities to file fraudulent Medicare claims. This case stems from the investigation of Jasper Ogbonna, owner of Matrix Medical Equipment & Supply (Matrix). Ogbonna was convicted in federal court in connection with Medicare claims which were also Texas Medicaid crossover claims. The beneficiaries became victims of identity theft. 16

17 Attorney General Abbott announced on January 24 that Bolade Abioye and Abiodun Kutemi were indicted by a state grand jury for theft by government contract. Abioye is owner/operator of Zion Medical Supply (ZMS) and Kutemi is owner/operator of Insight Medical Supply (IMS). IMS allegedly billed Medicaid through ZMS for incontinence supplies, power wheelchairs/scooters and a walker that were not provided to recipients. For further information on these cases contact Rick Copeland, Director or Chief Investigator Travis Tucker (512) Medical Transportation: Ohio Attorney General DeWine on February 8 that Ademola Gbadegesin was sentenced to 30 months in prison, three years of supervised release, six months of house arrest, and ordered to pay restitution in the amount of $327, On April 13, 2011, an indictment was filed charging Gbadegesin with five counts of health care fraud all federal charges. On October 17, 2011, Gbadegesin pleaded guilty to five counts of health care fraud. Gbadegesin owner of Suntun Medical Transportation, billed for services for ambulatory recipients, billed for dates when no services took place, and billed for an extra attendant that was never present For further information contact Assistant Attorney General Constance Nearhood (614) 466- Medical Transportation: Texas Attorney General Abbott announced on January 20 that Erika Rojas, Michael Zamora, and Priscilla Rojas pleaded guilty in federal court to theft of funds from a health care benefit program. On January 5, former state employee Caroline Hernandez also pleaded guilty to theft of funds from a health care benefit program. Eighteen individuals, including seven former state employees, were indicted for health care fraud, theft or embezzlement in connection with health care, and false statements related to health care matters. The former state employees worked for the Medical Transportation Program call center, where they allegedly authorized advance payments to be issued to relatives or friends for Medicaid recipients' transportation to medical appointments. Attorney General Abbott announced in February that Veronica Zamora, Angela Grado, Leticia Orosco, Michelle Garcia, and Michelle Aguilar pleaded guilty in federal court to theft of funds from a health care benefit program. Seven former state employees, and 11 others were indicted for health care fraud, theft or embezzlement in connection with health care, and false statements related to 17

18 health care matters. The former state employees worked for the Medical Transportation Program call center where they allegedly authorized advance payments to be issued to relatives or friends for Medicaid recipients transportation to medical appointments. The appointments were allegedly never scheduled. For further information on both cases contact Rick Copeland, Director or Chief Investigator Travis Tucker (512) Nurses: Ohio Attorney General DeWine announced on January 24 that Charlotte Manley pleaded guilty to one count of attempted forgery, a misdemeanor of the first degree and was sentenced to one day in jail sentence suspended for time served. On October 18, 2011, an indictment was filed charging Manley with two counts of complicity to commit forgery, felonies of the fifth degree. Manley, an RN, signed plans of care for an LPN that she was supervising after the date of care was given. Nurses: Texas For further information contact Assistant Attorney General Shawn Napier (614) Attorney General Abbott announced on January 24 that licensed vocational nurse (LVN) Nicole Contreras was indicted by a state grand jury for fraud. LVN Contreras, while working at the Lubbock Health Care Center, allegedly became lethargic, slow to respond to verbal commands, had glassy eyes and refused treatment from EMS. LVN Contreras's medication cart was counted and narcotics were missing. For further information contact Rick Copeland, Director or Chief Investigator Travis Tucker (512) Nurse Aides: Colorado Attorney General John Suthers announced on November 8, 2011 that Sharon Ludwig pleaded guilty to all charges on the complaint/information filed against her. The charges included one count of forgery of a public record, a class 5 felony, and one count of offering a false instrument for recording in the first degree, a class 5 felony. Ludwig, a certified nurse aide, submitted falsified timesheets and billing statements in order to obtain payment from Medicaid for services that were not rendered. For further information contact Assistant Attorney General Richard Ferro or Criminal Investigator Bruce Norton (303)

19 Attorney General Suthers announced on February 10 that Rina Diana pleaded guilty and was sentenced on two counts; nurse aide-unauthorized practice, a class two misdemeanor, and criminal possession of an identification documents, a class six felony. She received two years of supervised probation, 24 hours of useful public service, and was ordered to pay court costs and fees for the nurse aide-unauthorized practice count. On the count of criminal possession of an identification document, she received a sentence of supervised probation for two years concurrent to the previous count, and ordered to perform 24 hours of useful public service for a total of 48 hours. The convictions stemmed from Diana s use of a false nurse-aide license, and her possession of a false Social Security card and a false drivers license in order to obtain payments from Medicaid. For further information contact Assistant Attorney General Richard Ferro (303) or Criminal Investigator Kerry Sanchez (303) Pain Clinics: Ohio Attorney General DeWine announced on February 6 that Dannette Hawthorne was sentenced to 12 years in prison, three years of supervised release, ordered to pay a $400 fine and ordered to pay restitution in the amount of $29, On December 21, 2011, an indictment was filed charging Hawthorne with one count of conspiracy to distribute controlled substance, one count of conspiracy to commit health care fraud, one count of submission of fraudulent claims, and one count of aggravated identity theft all federal charges. On March 31, 2011, Hawthorne pleaded guilty to one count of conspiracy to distribute controlled substance, one count of conspiracy to commit health care fraud, one count of submission of fraudulent claims, and one count of aggravated identity theft all federal charges. Hawthorne owned and operated two pain clinics. Hawthorne contracted with doctors to see patients for a short period of time then began to forge doctors signatures on prescriptions. For further information contact Assistant Attorney General Shawn Napier (614) Pharmacies: Texas Attorney General Abbott announced on February 3 that pharmacist Sara E. Garza pleaded guilty in federal court to conspiracy to commit health care fraud. Garza, owner of Sara s Pharmacy & Gift Corner, and pharmacy tech Valerie J. Flores allegedly billed Medicaid for medications that did not have a valid prescription and refilled prescriptions without authorization. Flores pleaded guilty in December 2011 to conspiracy to commit health care fraud. The identified overpayment is over $1.1 million. 19

20 Attorney General Abbott announced on February 13 that certified nurses' aide (CNA) Maria Estrada was given four years deferred adjudication community supervision and was fined $2,500 and ordered to undergo substance abuse counseling after pleading guilty in state court to 12 counts of controlled substance fraud. CNA Estrada, while employed with Dumas Nursing and Rehabilitation, allegedly diverted hydrocodone from patients for her own use. For further information on these cases contact Rick Copeland, Director or Chief Investigator Travis Tucker (512) Physicians: Tennessee The Tennessee Medicaid Fraud Control Unit announced on August 29, 2011 that Otolaryngology Consultants of Memphis, PC, was sentenced in the United States District Court for the Western District of Tennessee after pleading guilty to health care fraud. Otolaryngology Consultants was ordered to pay a fine of $500,000 and an assessment fee of $400. This case was opened on February 5, 2005, based on a qui tam that was filed earlier that year in the Western District of Tennessee. It was alleged that Otolaryngology was billing for services of unlicensed physicians as if they were licensed. Also, it was alleged they were falsifying records to justify their billing, unbundling and upcoding visits. For further information contact Special Agent Terry Reed (901) The Tennessee Medicaid Fraud Control Unit announced on August 1, 2011 that Allen Ricardo Foster, MD, pleaded guilty in the United States District Court of Eastern District of Tennessee to one count of health care fraud and one count of failure to file federal income tax. Foster was sentenced to 12 months and one day in federal prison and placed on supervised probation for three years. Additionally, Foster was ordered to pay restitution in the amount of $596, to Internal Revenue Service, $74,307 to Medicare, $65,837 to TennCare, and a $125 assessment. This case was opened on March 26, 2007, based on a referral from the Department of Finance and Administration, Office of Inspector General, State of Tennessee. It was alleged that Foster was overprescribing controlled narcotics and issuing prescriptions without an examination. For further information contact Special Agent David Slagle (423)