Articles Posted in Medical Fraud

Last Monday, a federal government report announced that over $2.5 billion in Southern California Medicare fraud (and fraud elsewhere) was recovered in 2010. The 84 page report from the Justice and Health & Human Services found that the government’s anti-fraud programs appear to be working well – returning $5 for every dollar spent to combat fraud. Defendants have included hospitals, physicians, manufacturers of medical devices, and pharmaceutical companies.

A CNN report singled out the fraud case of a Tustin, California CFO as “one of the most blatant cases” last year. The CFO pled guilty in April 2010 to charges of recruiting homeless people to engage in unnecessary services in exchange for kickbacks. He was one of 726 different defendants convicted for crimes like Los Angeles healthcare fraud and insurance fraud.

2011 may be an even more vigorous year for anti-fraud activists. The Justice and Health and Human Services report says that over 1,100 new fraud probes will be launched in 2011. 1,700 criminal investigations are pending. And the universe of potential defendants may expand to 2,000+ people. Since the late 1990s, the government has collected approximately $18 billion from individuals and institutions that have committed fraud against Medicare and other healthcare programs.

The annals of Southern California medical, dental and chiropractic fraud are replete with pretty crazy stories. But a breaking story out of Columbus, Ohio may have even the most tawdry recent Los Angeles white collar crime stories beat. An Ohio area doctor, Charles Njoku, has been sentenced for manipulating his receptionist into posing as a doctor to treat patients and bilk Medicare and Medicaid.

Judge Algenon L. Marbley sentenced Dr. Njoku in District Court to a year of home confinement, three-years of probation, and 416 hours of community service. He must also pay over $130,000 in restitution to Medicare and Medicaid programs. Dr. Njoku — whose medical license has not yet been suspended, according to the Columbus Dispatch — should be counting as blessings. The judge could have sentenced him to three decades behind bars and a fine of $1.5 million for his crimes.

His receptionist and co-conspirator, Veronica Scott-Guiler, was also arrested for medical fraud back in January. Scott-Guiler also pled guilty and received a similar sentence. She, too, could have been hit with much harsher penalties – including up to 15 years behind bars. Although the judge did let the Nigerian-born Njoku off relatively easily, he had harsh words for the defendant: “You should be ashamed… you don’t have the excuse [of a poor upbringing] that many of the defendants who come before me have…the good deeds [you] have done are eviscerated by the nefarious deeds committed.”

Although Southern California healthcare fraud is an enormous and perennial problem – witness the massive Armenian Mafia Medicare scam story that broke in October 2010 – the city of Miami, Florida remains the “national epicenter for Medicare fraud,” according to a story in the AP from five days ago.

The latest big breaking Medicare scam involves the drug Arformoterol, an emphysema and bronchitis drug. The Department of Health and Human Services reports that, over a year-and-a-half long period, Miami-Dade County healthcare providers paid out $34 million for drugs that should have only cost about $3.7 million. Medicare paid for 7 million units but only received 750,000 units. The fraud, which totaled more than $30 million, sounds like a big deal. But $30 million is peanuts compared with the total Medicare fraud committed annually in Miami – “roughly $3 billion,” according to the AP.

The arformoterol overbilling scheme is just one of dozens of similar scams recently perpetrated by technically savvy crooks. According to the AP, “The spike in arformoterol only came after authorities tried to crack down on another inhaler drug… as authorities have caught onto one scam, crooks have moved on to another, such as by shifting from durable medical equipment and HIV drug scams to physical therapy and home healthcare fraud.”

The Wall Street Journal, Washington Post, Bloomberg News and other major media services are reporting on an enormous Los Angeles medical fraud (and elsewhere) settlement involving three pharmaceutical firms: Abbott Laboratories, B. Braun Medical of Bethlehem, Pennsylvania, and Roxane Laboratories of Columbus, Ohio. All told, the $420+ million settlement stemmed from a whistleblower charge pursuant to the False Claims Act.

Essentially, the drug companies overinflated their benchmark pricing to government insurers. In other words, they gave pharmacies and doctors a discounted price, and then they inflated how much the drugs cost and passed that difference onto the taxpayers. This illegal inflation became so well known that the benchmark — called the Average Wholesale Price (AWP) — soon became known among everyone in the industry as “ain’t what’s paid.” A spokesman for the Justice Department put it bluntly: “The only persons who paid the inflated, reported drug price were you, the American taxpayers.”

Cases of medical, dental, and chiropractic fraud, insurance fraud, credit card fraud, and other Southern California white collar crimes are significant and troubling. But the typical local cases pale in comparison with the national Medicare and Medicaid schemes unraveled by the Justice Department recently. Here is a quick recap of a few jaw dropping settlements: