Medical Clinic Fraud
The owner of a Miami-based medical clinic was recently sentenced to 60 months in prison for directing a $38 million healthcare fraud scheme. Armando Valdes also was ordered to forfeit four real estate properties, including a beachfront condo in Pompano Beach, as well as numerous luxury vehicles, including a Cadillac Escalade and a Tesla Model S, all of which he had purchased using ill-gotten proceeds.
The scheme is alleged to have taken place from February 2015 through July 2021. Valdes owned and operated Gasiel Medical Services, Corp., a medical clinic in Miami. Valdes submitted approximately $38 million in fraudulent claims to United Healthcare and Blue Cross Blue Shield for infusions of the prescription drug Infliximab, known by the brand name Remicade. Infliximab is one of the most expensive prescription drugs on the market—a single dose can have a retail price of nearly $10,000.
Despite claiming approximately $38 million in reimbursements for infusions of Infliximab purportedly provided to patients, Valdes admitted as part of his guilty plea earlier this year, that he never provided even a single infusion of the drug, nor did patients of the clinic require the medication.
An Iowa dermatologist agreed to pay $1.66 million to resolve allegations he violated the False Claims Act by submitting claims that were upcoded to Medicare for dermatology office visits and the destruction or removal of skin tags and lesions.
Upcoding is considered a false claim because it involves exaggerating the amount or complexity of medical services rendered in order to achieve a higher level of reimbursement—a form a fraud.
The case involved Dr. Manish G. Kumar and Eastern Iowa Dermatology, PLC and the alleged incidents took place from April 1, 2013 through Sept. 30, 2019, according to prosecutors. In addition to the payment, Kumar also agreed to an Integrity Agreement and will submit to ongoing monitoring by the U.S. Department of Health and Human Services.
A North Carolina woman was convicted by a federal jury for her role in a scheme to defraud several private health insurers by submitting more than $34 million in false and fraudulent claims for physical therapy services that were never actually provided.
Jaroslava Ruiz of Chapel Hill, was charged with paying kickbacks and bribes to patient recruiters and patients with private insurance in exchange for allowing four Miami physical therapy clinics to bill for medical services that were never provided. Ruiz and her co-conspirators falsified medical records to give the impression that the physical therapy services were medically necessary, prescribed by a doctor, and actually rendered.
Ruiz and her co-conspirators submitted approximately $34.6 million in false and fraudulent claims to several private insurers for those nonexistent physical therapy services, of which the insurers paid approximately $7.7 million.
Ruiz was convicted of one count of conspiracy to commit healthcare fraud and wire fraud, and nine counts of healthcare fraud. She faces up to 20 years in prison on the conspiracy count, and up to 10 years in prison on each healthcare fraud count. Sentencing is set for October.
Nursing Home Fraud
Five individuals and two for-profit skilled nursing facilities in Southwestern Pennsylvania were indicted by federal grand jury in Pittsburgh on charges of conspiracy to defraud the United States and related healthcare fraud charges.
The 15-count Superseding Indictment, returned on August 5, named Sam Halper, 39, of Miami Beach, Fla.; Eva Hamilton, 35, of Beaver, Pa.; Susan Gilbert, 61, of Lawrence, Pa.; Michelle Romeo, 46, of Hillsville, Pa.; and Johnna Haller, 41, of Monaca, Pa., as co-defendants.
It was alleged that the five were involved in a scheme to defraud the U.S. healthcare system by changing staffing records to indicate patients were getting care when they were not and by adding ailments to patient files in order to get more government reimbursement.
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