in Federal Criminal Cases Nationwide
Health Care Fraud
Jon May is available to represent individuals who are who under investigation or being prosecuted for Health Care Fraud.
Health Care Fraud can be committed by medical providers, patients, and others who intentionally deceive the health care system to receive unlawful benefits or payments.
The FBI is the primary agency for investigating health care fraud, for both federal and private insurance programs.
The Most Common Types of Health Care Fraud
Fraud Committed by Medical Providers
- Double billing: Submitting multiple claims for the same service
- Phantom billing: Billing for a service visit or supplies the patient never received
- Unbundling: Submitting multiple bills for the same service
- Upcoding: Billing for a more expensive service than the patient actually received
Fraud Committed by Patients and Other Individuals
- Bogus marketing: Convincing people to provide their health insurance identification number and other personal information to bill for non-rendered services, steal their identity, or enroll them in a fake benefit plan
- Identity theft/identity swapping: Using another person’s health insurance or allowing another person to use your insurance
- Impersonating a health care professional: Providing or billing for health services or equipment without a license
Fraud Involving Prescriptions
- Forgery: Creating or using forged prescriptions
- Diversion: Diverting legal prescriptions for illegal uses, such as selling your prescription medication
- Doctor shopping: Visiting multiple providers to get prescriptions for controlled substances or getting prescriptions from medical offices that engage in unethical practices
The National Heath Care Anti-Fraud Association estimates conservatively that health care fraud costs the nation about $68 billion annually — about 3 percent of the nation’s $2.26 trillion in health care spending. Other estimates range as high as 10 percent of annual health care expenditure, or $230 billion.
The kinds of fraud committed on the federal government and health insurance companies are too numerous to mention. But one example illustrates the breath of the problem.
On September 17, 2021, the Department of Justice announced criminal charges against 138 defendants, including 42 doctors, nurses, and other licensed medical professionals, charged between August 1 and September 17, 2021, in 31 federal districts for their alleged participation in various health care fraud and illegal opioid distribution schemes that resulted in a combined total of approximately $1.4 billion in alleged losses. The charges targeted approximately $1.1 billion in alleged fraud committed using telemedicine (the use of telecommunications technology to provide health care services remotely), $29 million in COVID-19 health care fraud, $133 million connected to substance abuse treatment facilities, or “sober homes,” and $160 million connected to other health care fraud and illegal opioid distribution schemes across the country.
Other examples of health care fraud.
Press Release – Friday, February 25, 2022
Ten Florida Residents Indicted for $67 Million Health Care Fraud, Wire Fraud, Kickback, and Money Laundering Scheme
WASHINGTON – Ten Florida residents were charged in an indictment unsealed today in the Southern District of Florida for their alleged roles in a $67 million health care fraud, wire fraud, kickback, and money laundering scheme involving the submission of false and fraudulent claims to Medicare for medically unnecessary genetic tests and durable medical equipment.
The indictment alleges that, between January 2020 and July 2021, the defendants referred Medicare beneficiaries for medically unnecessary genetic tests and durable medical equipment. In exchange for doctors’ orders for such tests and equipment, the defendants allegedly paid kickbacks and bribes to telemedicine companies. The indictment further alleges that the defendants falsified Medicare enrollment forms to conceal the true owners and managers of certain laboratories, and submitted false and fraudulent claims to Medicare.
Ten Florida Residents Indicted for $67 Million Health Care Fraud, Wire Fraud, Kickback, and Money Laundering Scheme – U.S. Department of Justice
Press Release – Monday, May 3, 2021
Three Florida Men Charged in $46 Million Health Care Fraud, Kickback, and Money Laundering Conspiracy
Miami, Fl. – Three telemarking company owners were charged for their alleged participation in a $47 million health care fraud, kickback, and money laundering scheme involving the referral of medically unnecessary cancer genetic tests to labs in exchange for kickbacks.
According to the indictment, McKeon and Ziros allegedly participated in a scheme to operate a telemarketing campaign targeting Medicare beneficiaries in an effort to induce them to accept cancer genetic tests regardless of whether the tests were medically necessary or eligible for Medicare reimbursement. As part of the scheme, McKeon and Ziros allegedly offered and paid illegal kickbacks and bribes to telemedicine companies in exchange for doctors’ orders for expensive cancer genetic tests. The doctors’ orders were written by doctors contracted with telemedicine companies, even though those telemedicine doctors had no prior relationship with the beneficiaries, were not treating the beneficiaries for cancer or symptoms of cancer, did not use the test results in the treatment of the beneficiaries, and did not conduct a proper telemedicine visit.
According to court documents, all three men sold these signed doctors’ orders for cancer genetic tests to labs in exchange for illegal kickbacks. The indictment and information allege that the defendants caused one of the labs to submit approximately $46 million in claims to Medicare, of which over $27 million was paid. The indictment further alleges that the lab paid McKeon, Ziros, and others kickbacks totaling over $14 million, and that McKeon and Ziros laundered these unlawful proceeds knowing that the transactions at issue had been designed to conceal and disguise the nature, source, and control of the proceeds.
Three Florida Men Charged in $46 Million Health Care Fraud, Kickback, and Money Laundering Conspiracy – U.S. Department of Justice
Press Release – Tuesday, March 9, 2021
Pharmacy Owner and Accountant Indicted in $134M Health Care Fraud Scheme
HOUSTON – Two Houston area men are now in custody on charges of conspiracy to commit health care fraud relating to a pharmacy fraud scheme, announced Acting U.S. Attorney Jennifer Lowery.
4M Pharmaceuticals Inc. was the parent company for several retail pharmacies that operated in Houston, Fort Worth, South Florida and elsewhere, according to the charges. Mokbel was 4M’s CEO and allegedly had ownership interests in the subsidiary pharmacies. The charges allege Elsafty served as 4M’s accountant and tax preparer as well as nominee owner of the multiple pharmacies.
4M Pharmaceuticals allegedly functioned as an outbound telemarketing call center that solicited Medicare, Medicaid and commercial insurance patients nationwide – many over the over the age of 55. The indictment alleges call center employees offered patients medically unnecessary diabetic supplies and topical creams although many refused the solicitations. However, 4M Pharmaceuticals and pharmacies allegedly billed the patient’s insurance plan anyway. In some cases, 4M pharmacies billed for prescriptions dispensed after a patient’s death, according to the allegations.
The scheme also allegedly targeted doctors. The charges allege 4M Pharmaceuticals sent fax requests for prescriptions that patients often did not authorize. In several cases, the company billed patients for prescription drugs without a valid prescription, according to the allegations. 4M pharmacies also allegedly sent prescription requests to doctors for dead patients.
Pharmacy Owner and Accountant Indicted in $134M Health Care Fraud Scheme – U.S. Department of Justice