WASHINGTON—Two former owners of a Los Angeles-area medical equipment wholesale supply company pleaded guilty today to conspiring with their customers to defraud Medicare.
The pleas were announced by Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; U.S. Attorney André Birotte, Jr. of the Central District of California; Glenn R. Ferry, Special Agent in Charge for the Los Angeles Region of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG); Bill L. Lewis, Assistant Director in Charge of the FBI’s Los Angeles Field Office; and Joseph Fendrick, Special Agent in Charge of the California Department of Justice, Bureau of Medi-Cal Fraud and Elder Abuse (Cal-DOJ).
Rajinder Singh Paul, 69, and Baljit Kaur Paul, 65, of Redlands, California, each pleaded guilty before U.S. District Judge Percy Anderson in the Central District of California to one count of conspiracy to commit health care fraud.
In court documents, Rajinder and Baljit Paul admitted that they were the president and vice president, respectively, and shareholders of AHPK Inc., a medical equipment wholesale supply company located in Redlands and Ontario, California, and formally known as Major’s Wholesale Medical Supply Inc. The Pauls later sold Major’s Wholesale Medical Supply Inc. to Major’s Wholesale Medical Supply LLC (collectively, “Major’s”) and, according to court documents, remained employed at Major’s Wholesale Medical Supply LLC as consultants until they were terminated in February 2009.
During the time the Pauls either owned or worked as consultants for Major’s, Major’s sold durable medical equipment (DME) almost exclusively to customers who owned and operated DME supply companies, according to court documents. A majority of Major’s customers were Medicare providers and relied on Medicare to make money, which they did by billing Medicare for the DME that they purchased from Major’s.
One of the more popular items of DME that the Pauls sold at Major’s were power wheelchairs. Court documents indicate that to attract customers, the Pauls sold power wheelchairs to Major’s customers wholesale for between $850 to $1,000 each. Major’s customers, however, billed these power wheelchairs to Medicare at a rate of between $3,000 to $6,000 per wheelchair.
The Pauls admitted they knew that Major’s customers were dependent on Medicare for their revenue and that Major’s customers could not pay Major’s unless Medicare paid the customers first. To foster customer loyalty, the Pauls engaged in a variety of conduct over a period of six years that helped Major’s customers defraud Medicare, including by providing Major’s customers with false inventory purchase agreements that showed they had higher credit limits than they really did. Major’s customers submitted these false inventory purchase agreements to Medicare to prove, as required by Medicare, the ability to purchase the volume of DME they billed.
The Pauls also admitted they provided Major’s customers with backdated invoices, knowing customers were billing Medicare for power wheelchairs and DME before the customers actually purchased or delivered the equipment. The Pauls admitted that by backdating these invoices, they provided Major’s customers with the paper trail the customers needed to prove to Medicare that they had both purchased the DME and purchased it before they submitted their claims to Medicare. According to court documents, the Pauls backdated or falsified invoices for more than 100 different customers.
Court documents indicate that two of many customers who conspired with the Pauls to defraud Medicare owned and operated a number of fraudulent DME supply companies in the Los Angeles area, including one customer who used “straw,” or nominee, owners to operate the customer’s companies. The Pauls admitted they provided these two customers with false inventory purchase agreements and backdated invoices that the customers used to defraud Medicare. The Pauls admitted that as a result of their conduct, these two customers were able to use their fraudulent DME supply companies to submit approximately $16,662,143 in false claims to and receive approximately $9,743,609.42 in ill-gotten reimbursement payments from Medicare.
At sentencing, scheduled for July 8, 2013, the Pauls each face a maximum penalty of 10 years in prison and a $250,000 fine.
This case is being prosecuted by Jonathan T. Baum of the Criminal Division’s Fraud Section. The case was investigated by the FBI, HHS-OIG, and Cal DOJ and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Central District of California.
Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,480 defendants who have collectively billed the Medicare program for more than $4.8 billion. In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers. To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to www.stopmedicarefraud.gov
Wednesday, February 27, 2013
Old Saybrook Physical Therapist Sentenced, Agrees to Pay $328,828 to Resolve False Claims Act Liability
The United States Attorney for the District of Connecticut announced that Todd Roberts, 47, of Old Saybrook, was sentenced today by United States District Judge Stefan R. Underhill in Bridgeport to three years of probation for obstructing a federal audit. Roberts and his physical therapy practice, Roberts Physical and Aquatics Therapy, also have entered into a civil settlement agreement with the government in which they will pay $328,828 to resolve allegations that they violated the False Claims Act.
According to court documents and statements made in court, on January 23, 2009, a Medicare contractor informed Roberts Physical and Aquatics Therapy, located at 210 Main Street in Old Saybrook, that the contractor was performing an audit of the practice. Roberts instructed an employee to delay the audit by telling the contractor that medical records were stored at a nonexistent storage facility. Roberts then rented a storage unit at a local facility and used the delay to alter and augment patient records. Specifically, Roberts and an employee at his direction created and added patient progress notes when no notes had been created at the time of service. The notes made it appear as though Medicare beneficiaries had obtained direct, one-on-one service from a licensed physical therapist when, in fact, some of the services had been rendered by unlicensed auxiliary personnel.
On September 25, 2012, Roberts waived his right to indictment and pleaded guilty to one count of obstructing a federal audit.
The civil allegations against Roberts and Roberts Physical and Aquatics Therapy involve improper billing to Medicare for physical and aquatic therapy services between April 2007 and March 2010. The Medicare program only pays for outpatient therapy services that are provided by qualified personnel. Personnel qualified to provide outpatient therapy services are limited to physicians, licensed physical therapists, and licensed physical therapy assistants. The Medicare program does not pay for physical therapy services provided by supportive personnel, such as physical therapy aides, athletic trainers, or student trainees. In addition, Medicare regulations and policies make it clear that therapeutic procedures require direct, one-on-one contact between the licensed therapist and the patient.
The government alleges that Roberts and Roberts Physical and Aquatics Therapy regularly billed Medicare for direct, one-on-one therapeutic procedures when such services were not provided. At the clinic, physical therapists and physical therapy assistants would routinely provide therapy services to multiple patients at the same time. Nevertheless, the services provided to each patient were billed as if the physical therapist or physical therapy assistant had provided direct, one-on-one care. For example, patients were routinely left alone to perform exercises in the aquatic therapy pool, with no direct, one-on-one contact with licensed personnel.
In addition, Medicare regulations and policies make it clear that physical therapy services must be thoroughly and accurately documented in the patients’ medical chart. Therapy services are only payable when the medical record consistently and accurately records the covered therapy services. The government alleges that Roberts and Roberts Physical and Aquatics Therapy routinely failed to document their therapy services. This was particularly egregious during the first six months of its operation, when the clinic did not have any documentation at all showing that the services in question were actually provided.
To resolve their liability under the False Claims Act, Roberts Physical and Aquatics Therapy will pay $328,828 for conduct occurring between April 5, 2007 and March 31, 2010.
In addition, Roberts and Roberts Physical and Aquatics Therapy have entered into a six-year Integrity Agreement with the U.S. Department of Health and Human Services that is designed to ensure future compliance with the requirements of the Medicare program, including the proper rendering of therapy services and the submission of only valid claims to Medicare for payment.
In entering into the civil settlement agreement, Roberts and Roberts Physical and Aquatics Therapy did not admit liability.
Judge Underhill required Roberts, as conditions of his probation, to comply with the terms of the Integrity Agreement and to pay the entire $328,828.
This matter was investigated by the Office of Inspector General for the Department of Health and Human Services, the Federal Bureau of Investigation, and the Office of the Inspector General for the Department of Veterans Affairs. The case was prosecuted by Assistant United States Attorneys David J. Sheldon and Richard M. Molot, and Auditor Susan Spiegel.
People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS or the Health Care Fraud Task Force at (203) 777-6311.
According to court documents and statements made in court, on January 23, 2009, a Medicare contractor informed Roberts Physical and Aquatics Therapy, located at 210 Main Street in Old Saybrook, that the contractor was performing an audit of the practice. Roberts instructed an employee to delay the audit by telling the contractor that medical records were stored at a nonexistent storage facility. Roberts then rented a storage unit at a local facility and used the delay to alter and augment patient records. Specifically, Roberts and an employee at his direction created and added patient progress notes when no notes had been created at the time of service. The notes made it appear as though Medicare beneficiaries had obtained direct, one-on-one service from a licensed physical therapist when, in fact, some of the services had been rendered by unlicensed auxiliary personnel.
On September 25, 2012, Roberts waived his right to indictment and pleaded guilty to one count of obstructing a federal audit.
The civil allegations against Roberts and Roberts Physical and Aquatics Therapy involve improper billing to Medicare for physical and aquatic therapy services between April 2007 and March 2010. The Medicare program only pays for outpatient therapy services that are provided by qualified personnel. Personnel qualified to provide outpatient therapy services are limited to physicians, licensed physical therapists, and licensed physical therapy assistants. The Medicare program does not pay for physical therapy services provided by supportive personnel, such as physical therapy aides, athletic trainers, or student trainees. In addition, Medicare regulations and policies make it clear that therapeutic procedures require direct, one-on-one contact between the licensed therapist and the patient.
The government alleges that Roberts and Roberts Physical and Aquatics Therapy regularly billed Medicare for direct, one-on-one therapeutic procedures when such services were not provided. At the clinic, physical therapists and physical therapy assistants would routinely provide therapy services to multiple patients at the same time. Nevertheless, the services provided to each patient were billed as if the physical therapist or physical therapy assistant had provided direct, one-on-one care. For example, patients were routinely left alone to perform exercises in the aquatic therapy pool, with no direct, one-on-one contact with licensed personnel.
In addition, Medicare regulations and policies make it clear that physical therapy services must be thoroughly and accurately documented in the patients’ medical chart. Therapy services are only payable when the medical record consistently and accurately records the covered therapy services. The government alleges that Roberts and Roberts Physical and Aquatics Therapy routinely failed to document their therapy services. This was particularly egregious during the first six months of its operation, when the clinic did not have any documentation at all showing that the services in question were actually provided.
To resolve their liability under the False Claims Act, Roberts Physical and Aquatics Therapy will pay $328,828 for conduct occurring between April 5, 2007 and March 31, 2010.
In addition, Roberts and Roberts Physical and Aquatics Therapy have entered into a six-year Integrity Agreement with the U.S. Department of Health and Human Services that is designed to ensure future compliance with the requirements of the Medicare program, including the proper rendering of therapy services and the submission of only valid claims to Medicare for payment.
In entering into the civil settlement agreement, Roberts and Roberts Physical and Aquatics Therapy did not admit liability.
Judge Underhill required Roberts, as conditions of his probation, to comply with the terms of the Integrity Agreement and to pay the entire $328,828.
This matter was investigated by the Office of Inspector General for the Department of Health and Human Services, the Federal Bureau of Investigation, and the Office of the Inspector General for the Department of Veterans Affairs. The case was prosecuted by Assistant United States Attorneys David J. Sheldon and Richard M. Molot, and Auditor Susan Spiegel.
People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS or the Health Care Fraud Task Force at (203) 777-6311.
Miami Pharmacy Owner Sentenced to 14 Years in Prison in $23 Million Health Care Fraud Scheme
WASHINGTON—A co-owner and operator of three Miami discount pharmacies was sentenced today to 168 months in prison for his role in a health care fraud scheme that submitted more than $23 million in false claims to Medicare.
The sentence was announced by Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Michael B. Steinbach, Special Agent in Charge of the FBI’s Miami Field Office; and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Office of Investigations Miami Office.
Jose Carlos Morales, 55, of Miami, was sentenced by U.S. District Judge Joan A. Lenard in the Southern District of Florida. In addition to his prison term, Morales was sentenced to serve three years of supervised release and to pay a $100,000 fine. A hearing to determine the amount of restitution Morales will pay has been scheduled for April 29, 2013.
On December 6, 2012, Morales pleaded guilty in the Southern District of Florida to one count of conspiracy to commit health care fraud and one count of conspiracy to defraud the United States and pay illegal health care kickbacks.
According to court documents, Morales was the co-owner of Pharmovisa Inc. and PharmovisaMD Inc., which operated a total of three pharmacies in Miami. Morales paid illegal health care kickbacks to co-conspirators in return for a stream of beneficiary information to be used to submit claims to Medicare and Medicaid. The beneficiaries who were referred to the pharmacies in exchange for kickback payments resided at assisted living facilities (ALFs) located in Miami. Morales and his alleged co-conspirators also paid illegal health care kickbacks to physicians in exchange for prescription referrals, which the pharmacies ultimately billed to Medicare.
Court documents also reveal that beginning in approximately 2007, drivers working for Morales’ pharmacies, at his direction, delivered “bingo cards” containing pop-out medications to ALFs located throughout the Southern District of Florida. Morales instructed the drivers to pick up any unused “bingo cards” so that Morales pharmacy personnel could put the medications back into pill bottles. Unused and partially used medications were eventually re-billed to Medicare and Medicaid, and a majority of the previously submitted claims to Medicare and Medicaid were never reversed. Morales also instructed Morales pharmacy personnel to place unused and partially used medications into bottles to be sold directly to the general public from the “community” pharmacy shelves.
Morales and his alleged co-conspirators also engaged in sham financial transactions to facilitate and conceal the fraud schemes and the flow of fraud proceeds, according to court documents. In most instances, the sham transactions involved shell entities owned and/or controlled by Morales or his alleged co-conspirators.
According to court documents, Morales and his co-conspirators submitted and caused to be submitted approximately $23,367,755 in false and fraudulent claims to the Medicare and Florida Medicaid programs.
The case is being prosecuted by Trial Attorney Allan J. Medina and Special Trial Attorney William Parente of the Criminal Division’s Fraud Section. This case was investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida.
Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,480 defendants who have collectively billed the Medicare program for more than $4.8 billion. In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers. To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to www.stopmedicarefraud.gov.
The sentence was announced by Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Michael B. Steinbach, Special Agent in Charge of the FBI’s Miami Field Office; and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Office of Investigations Miami Office.
Jose Carlos Morales, 55, of Miami, was sentenced by U.S. District Judge Joan A. Lenard in the Southern District of Florida. In addition to his prison term, Morales was sentenced to serve three years of supervised release and to pay a $100,000 fine. A hearing to determine the amount of restitution Morales will pay has been scheduled for April 29, 2013.
On December 6, 2012, Morales pleaded guilty in the Southern District of Florida to one count of conspiracy to commit health care fraud and one count of conspiracy to defraud the United States and pay illegal health care kickbacks.
According to court documents, Morales was the co-owner of Pharmovisa Inc. and PharmovisaMD Inc., which operated a total of three pharmacies in Miami. Morales paid illegal health care kickbacks to co-conspirators in return for a stream of beneficiary information to be used to submit claims to Medicare and Medicaid. The beneficiaries who were referred to the pharmacies in exchange for kickback payments resided at assisted living facilities (ALFs) located in Miami. Morales and his alleged co-conspirators also paid illegal health care kickbacks to physicians in exchange for prescription referrals, which the pharmacies ultimately billed to Medicare.
Court documents also reveal that beginning in approximately 2007, drivers working for Morales’ pharmacies, at his direction, delivered “bingo cards” containing pop-out medications to ALFs located throughout the Southern District of Florida. Morales instructed the drivers to pick up any unused “bingo cards” so that Morales pharmacy personnel could put the medications back into pill bottles. Unused and partially used medications were eventually re-billed to Medicare and Medicaid, and a majority of the previously submitted claims to Medicare and Medicaid were never reversed. Morales also instructed Morales pharmacy personnel to place unused and partially used medications into bottles to be sold directly to the general public from the “community” pharmacy shelves.
Morales and his alleged co-conspirators also engaged in sham financial transactions to facilitate and conceal the fraud schemes and the flow of fraud proceeds, according to court documents. In most instances, the sham transactions involved shell entities owned and/or controlled by Morales or his alleged co-conspirators.
According to court documents, Morales and his co-conspirators submitted and caused to be submitted approximately $23,367,755 in false and fraudulent claims to the Medicare and Florida Medicaid programs.
The case is being prosecuted by Trial Attorney Allan J. Medina and Special Trial Attorney William Parente of the Criminal Division’s Fraud Section. This case was investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida.
Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,480 defendants who have collectively billed the Medicare program for more than $4.8 billion. In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers. To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to www.stopmedicarefraud.gov.
Manhattan Doctor Pleads Guilty to $8.5 Million Medicare Fraud Scheme
Preet Bharara, the United States Attorney for the Southern District of New York, announced that Dr. Roberto Aymat, a medical doctor, pled guilty today in Manhattan federal court to participating in a scheme to defraud Medicare out of approximately $8.5 million through the use of fraudulent HIV/AIDS clinics in New York. As part of the scheme, Aymat and others billed Medicare for medications that were never administered or that were administered but were medically unnecessary. He pled guilty before U.S. District Judge George B. Daniels. Three other participants in the scheme, Asmed Barrera, Augusto Guzman, and Jorge Rivero, previously pled guilty.
Manhattan U.S. Attorney Preet Bharara said, “Roberto Aymat used his medical license to perpetrate a multi-million-dollar fraud on Medicare—a program that provides a lifeline to its beneficiaries and that is struggling financially to stay afloat. His exploitation of this vital, taxpayer-funded program was egregious and with his plea today, he has been held to account.”
According to the complaint and the indictment filed in this case:
Aymat, along with Barrera, Guzman, Rivero, also a medical doctor, and others operated three medical clinics in New York City that purported to provide drug treatments to Medicare-eligible HIV/AIDS patients, but that were, in reality, health care fraud mills.
The defendants executed the fraudulent scheme by recruiting HIV/AIDS patients eligible for Medicare and paying them kickbacks in exchange for signing on as patients at the clinics. The defendants then used these patients’ status as Medicare beneficiaries to submit claims for reimbursement to Medicare for drugs that had been prescribed to these patients. In fact, these medications were never purchased and never administered, or were administered, but were medically unnecessary.
From January 2007 to April 2009, Aymat and his co-conspirators billed Medicare for more than 10 times the number of units of prescription drugs they actually purchased, defrauding the Medicare system of at least $8.5 million.
Aymat, 44, a resident of Manhattan, pled guilty to conspiring to commit fraud in connection with a health care benefits program and to committing healthcare fraud and mail fraud. He faces a penalty of up to 50 years in prison and is scheduled to be sentenced by Judge Daniels on June 18, 2013.
Mr. Bharara praised the investigative work of the Federal Bureau of Investigation and the Department of Health and Human Services, Office of Inspector General, New York Region.
The prosecution is being handled by the Office’s Complex Frauds Unit. Assistant United States Attorneys Kan M. Nawaday and Jason H. Cowley are in charge of the prosecution.
Manhattan U.S. Attorney Preet Bharara said, “Roberto Aymat used his medical license to perpetrate a multi-million-dollar fraud on Medicare—a program that provides a lifeline to its beneficiaries and that is struggling financially to stay afloat. His exploitation of this vital, taxpayer-funded program was egregious and with his plea today, he has been held to account.”
According to the complaint and the indictment filed in this case:
Aymat, along with Barrera, Guzman, Rivero, also a medical doctor, and others operated three medical clinics in New York City that purported to provide drug treatments to Medicare-eligible HIV/AIDS patients, but that were, in reality, health care fraud mills.
The defendants executed the fraudulent scheme by recruiting HIV/AIDS patients eligible for Medicare and paying them kickbacks in exchange for signing on as patients at the clinics. The defendants then used these patients’ status as Medicare beneficiaries to submit claims for reimbursement to Medicare for drugs that had been prescribed to these patients. In fact, these medications were never purchased and never administered, or were administered, but were medically unnecessary.
From January 2007 to April 2009, Aymat and his co-conspirators billed Medicare for more than 10 times the number of units of prescription drugs they actually purchased, defrauding the Medicare system of at least $8.5 million.
Aymat, 44, a resident of Manhattan, pled guilty to conspiring to commit fraud in connection with a health care benefits program and to committing healthcare fraud and mail fraud. He faces a penalty of up to 50 years in prison and is scheduled to be sentenced by Judge Daniels on June 18, 2013.
Mr. Bharara praised the investigative work of the Federal Bureau of Investigation and the Department of Health and Human Services, Office of Inspector General, New York Region.
The prosecution is being handled by the Office’s Complex Frauds Unit. Assistant United States Attorneys Kan M. Nawaday and Jason H. Cowley are in charge of the prosecution.
Tuesday, February 26, 2013
Occupational Therapist Impersonator Sentenced to Prison for Mail Fraud and Identity Theft
ORLANDO—U.S. District Judge Roy Dalton sentenced James Lewis, a/k/a James Lee Lewis (44, Kissimmee), today to five years and five months in federal prison for mail fraud and aggravated identity theft. Lewis pleaded guilty on December 18, 2012.
According to court documents, in March 2009, Lewis fraudulently obtained a temporary occupational therapist (OT) license from the Florida Department of Health. To obtain the temporary license, Lewis used a false name and Social Security number and fabricated his education credentials. Between March 2009 and July 2011, Lewis worked as an OT at various health care facilities in Central Florida and New Mexico and received his wages using Electronic Funds Transfers. On January 17, 2013, Lewis’ bond was revoked after the government discovered that he had again applied to work as an occupational therapist in Central Florida, using fraudulent information.
This case was investigated by the Federal Bureau of Investigation, the Florida Department of Law Enforcement, and the Florida Department of Health’s Division of Medical Quality Assurance, Orlando Unlicensed Activity Office. It was prosecuted by Assistant United States Attorney David Haas.
According to court documents, in March 2009, Lewis fraudulently obtained a temporary occupational therapist (OT) license from the Florida Department of Health. To obtain the temporary license, Lewis used a false name and Social Security number and fabricated his education credentials. Between March 2009 and July 2011, Lewis worked as an OT at various health care facilities in Central Florida and New Mexico and received his wages using Electronic Funds Transfers. On January 17, 2013, Lewis’ bond was revoked after the government discovered that he had again applied to work as an occupational therapist in Central Florida, using fraudulent information.
This case was investigated by the Federal Bureau of Investigation, the Florida Department of Law Enforcement, and the Florida Department of Health’s Division of Medical Quality Assurance, Orlando Unlicensed Activity Office. It was prosecuted by Assistant United States Attorney David Haas.
Old Saybrook Physical Therapist Sentenced, Agrees to Pay $328,828 to Resolve False Claims Act Liability
The United States Attorney for the District of Connecticut announced that Todd Roberts, 47, of Old Saybrook, was sentenced today by United States District Judge Stefan R. Underhill in Bridgeport to three years of probation for obstructing a federal audit. Roberts and his physical therapy practice, Roberts Physical and Aquatics Therapy, also have entered into a civil settlement agreement with the government in which they will pay $328,828 to resolve allegations that they violated the False Claims Act.
According to court documents and statements made in court, on January 23, 2009, a Medicare contractor informed Roberts Physical and Aquatics Therapy, located at 210 Main Street in Old Saybrook, that the contractor was performing an audit of the practice. Roberts instructed an employee to delay the audit by telling the contractor that medical records were stored at a nonexistent storage facility. Roberts then rented a storage unit at a local facility and used the delay to alter and augment patient records. Specifically, Roberts and an employee at his direction created and added patient progress notes when no notes had been created at the time of service. The notes made it appear as though Medicare beneficiaries had obtained direct, one-on-one service from a licensed physical therapist when, in fact, some of the services had been rendered by unlicensed auxiliary personnel.
On September 25, 2012, Roberts waived his right to indictment and pleaded guilty to one count of obstructing a federal audit.
The civil allegations against Roberts and Roberts Physical and Aquatics Therapy involve improper billing to Medicare for physical and aquatic therapy services between April 2007 and March 2010. The Medicare program only pays for outpatient therapy services that are provided by qualified personnel. Personnel qualified to provide outpatient therapy services are limited to physicians, licensed physical therapists, and licensed physical therapy assistants. The Medicare program does not pay for physical therapy services provided by supportive personnel, such as physical therapy aides, athletic trainers, or student trainees. In addition, Medicare regulations and policies make it clear that therapeutic procedures require direct, one-on-one contact between the licensed therapist and the patient.
The government alleges that Roberts and Roberts Physical and Aquatics Therapy regularly billed Medicare for direct, one-on-one therapeutic procedures when such services were not provided. At the clinic, physical therapists and physical therapy assistants would routinely provide therapy services to multiple patients at the same time. Nevertheless, the services provided to each patient were billed as if the physical therapist or physical therapy assistant had provided direct, one-on-one care. For example, patients were routinely left alone to perform exercises in the aquatic therapy pool, with no direct, one-on-one contact with licensed personnel.
In addition, Medicare regulations and policies make it clear that physical therapy services must be thoroughly and accurately documented in the patients’ medical chart. Therapy services are only payable when the medical record consistently and accurately records the covered therapy services. The government alleges that Roberts and Roberts Physical and Aquatics Therapy routinely failed to document their therapy services. This was particularly egregious during the first six months of its operation, when the clinic did not have any documentation at all showing that the services in question were actually provided.
To resolve their liability under the False Claims Act, Roberts Physical and Aquatics Therapy will pay $328,828 for conduct occurring between April 5, 2007 and March 31, 2010.
In addition, Roberts and Roberts Physical and Aquatics Therapy have entered into a six-year Integrity Agreement with the U.S. Department of Health and Human Services that is designed to ensure future compliance with the requirements of the Medicare program, including the proper rendering of therapy services and the submission of only valid claims to Medicare for payment.
In entering into the civil settlement agreement, Roberts and Roberts Physical and Aquatics Therapy did not admit liability.
Judge Underhill required Roberts, as conditions of his probation, to comply with the terms of the Integrity Agreement and to pay the entire $328,828.
This matter was investigated by the Office of Inspector General for the Department of Health and Human Services, the Federal Bureau of Investigation, and the Office of the Inspector General for the Department of Veterans Affairs. The case was prosecuted by Assistant United States Attorneys David J. Sheldon and Richard M. Molot, and Auditor Susan Spiegel.
People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS or the Health Care Fraud Task Force at (203) 777-6311.
According to court documents and statements made in court, on January 23, 2009, a Medicare contractor informed Roberts Physical and Aquatics Therapy, located at 210 Main Street in Old Saybrook, that the contractor was performing an audit of the practice. Roberts instructed an employee to delay the audit by telling the contractor that medical records were stored at a nonexistent storage facility. Roberts then rented a storage unit at a local facility and used the delay to alter and augment patient records. Specifically, Roberts and an employee at his direction created and added patient progress notes when no notes had been created at the time of service. The notes made it appear as though Medicare beneficiaries had obtained direct, one-on-one service from a licensed physical therapist when, in fact, some of the services had been rendered by unlicensed auxiliary personnel.
On September 25, 2012, Roberts waived his right to indictment and pleaded guilty to one count of obstructing a federal audit.
The civil allegations against Roberts and Roberts Physical and Aquatics Therapy involve improper billing to Medicare for physical and aquatic therapy services between April 2007 and March 2010. The Medicare program only pays for outpatient therapy services that are provided by qualified personnel. Personnel qualified to provide outpatient therapy services are limited to physicians, licensed physical therapists, and licensed physical therapy assistants. The Medicare program does not pay for physical therapy services provided by supportive personnel, such as physical therapy aides, athletic trainers, or student trainees. In addition, Medicare regulations and policies make it clear that therapeutic procedures require direct, one-on-one contact between the licensed therapist and the patient.
The government alleges that Roberts and Roberts Physical and Aquatics Therapy regularly billed Medicare for direct, one-on-one therapeutic procedures when such services were not provided. At the clinic, physical therapists and physical therapy assistants would routinely provide therapy services to multiple patients at the same time. Nevertheless, the services provided to each patient were billed as if the physical therapist or physical therapy assistant had provided direct, one-on-one care. For example, patients were routinely left alone to perform exercises in the aquatic therapy pool, with no direct, one-on-one contact with licensed personnel.
In addition, Medicare regulations and policies make it clear that physical therapy services must be thoroughly and accurately documented in the patients’ medical chart. Therapy services are only payable when the medical record consistently and accurately records the covered therapy services. The government alleges that Roberts and Roberts Physical and Aquatics Therapy routinely failed to document their therapy services. This was particularly egregious during the first six months of its operation, when the clinic did not have any documentation at all showing that the services in question were actually provided.
To resolve their liability under the False Claims Act, Roberts Physical and Aquatics Therapy will pay $328,828 for conduct occurring between April 5, 2007 and March 31, 2010.
In addition, Roberts and Roberts Physical and Aquatics Therapy have entered into a six-year Integrity Agreement with the U.S. Department of Health and Human Services that is designed to ensure future compliance with the requirements of the Medicare program, including the proper rendering of therapy services and the submission of only valid claims to Medicare for payment.
In entering into the civil settlement agreement, Roberts and Roberts Physical and Aquatics Therapy did not admit liability.
Judge Underhill required Roberts, as conditions of his probation, to comply with the terms of the Integrity Agreement and to pay the entire $328,828.
This matter was investigated by the Office of Inspector General for the Department of Health and Human Services, the Federal Bureau of Investigation, and the Office of the Inspector General for the Department of Veterans Affairs. The case was prosecuted by Assistant United States Attorneys David J. Sheldon and Richard M. Molot, and Auditor Susan Spiegel.
People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS or the Health Care Fraud Task Force at (203) 777-6311.
Friday, February 22, 2013
Augusta Optometrist Pleads Guilty to Health Care Fraud Charge
AUGUSTA, GA—Jeffrey Sponseller, 47, of Augusta, Georgia, pleaded guilty today before United States District Court Judge J. Randal Hall to submitting over $800,000 in fraudulent claims to Medicare.
Evidence presented at today’s guilty plea hearing showed that Sponseller, an optometrist and an owner of Eye Care One, located at 3152 Washington Road in Augusta, Georgia, submitted claims to Medicare for payment for eye examinations of nursing home patients. Instead of billing Medicare for the actual service he was providing at the nursing homes, Sponseller claimed that he was conducting the most expensive type of eye examination, which typically lasts 45 minutes. An example of this health care fraud presented at today’s guilty plea hearing involved a July 27, 2009 visit by Sponseller to a nursing home in Americus, Georgia, where Sponseller billed Medicare for 177 patients that he claimed to have examined individually for 45 minutes each during that one-day visit. As a result of this type of fraudulent billing, Medicare paid Sponseller for that type of eye exam more than any other doctor in the United States in 2009.
United States Attorney Edward J. Tarver said, “Health care fraud is a cancer on the financial health of our nation. In many cases, such as with this defendant, it is committed by professionals who are well educated and highly regarded. Whether that fraud is perpetrated by an optometrist willing to claim that he worked the equivalent of five-and-a-half days during a one-day visit to a nursing home—like this defendant did—or a medical equipment supplier that bills Medicare without authorization, the ultimate injury is to the American taxpayer. The United States Attorney’s Office and its law enforcement partners will actively pursue those who abuse our country’s health care programs for financial gain.”
Derrick L. Jackson, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General for the Atlanta region, said, “Any time false claims are submitted for payment, our nation’s health insurance programs and beneficiaries suffer. Protecting precious Medicare funds remains a top priority for the Inspector General and our law enforcement partners.”
Sponseller faces a maximum penalty of five years’ imprisonment and a fine of up to $250,000, in addition to paying restitution. The date for Sponseller’s sentencing hearing has not yet been scheduled.
FBI Special Agents Paul Kubala and Jason Gustin, U.S. Attorney’s Office Investigator Kimberly Reinken, HHS-OIG Special Agent David Graupner, and IRS Special Agents Roger Garland and Jeffrey Hale participated in the investigation of this case. Assistant United States Attorney David Stewart is prosecuting in this case. For additional information, please contact First Assistant United States Attorney James D. Durham at (912) 201-2547.
Evidence presented at today’s guilty plea hearing showed that Sponseller, an optometrist and an owner of Eye Care One, located at 3152 Washington Road in Augusta, Georgia, submitted claims to Medicare for payment for eye examinations of nursing home patients. Instead of billing Medicare for the actual service he was providing at the nursing homes, Sponseller claimed that he was conducting the most expensive type of eye examination, which typically lasts 45 minutes. An example of this health care fraud presented at today’s guilty plea hearing involved a July 27, 2009 visit by Sponseller to a nursing home in Americus, Georgia, where Sponseller billed Medicare for 177 patients that he claimed to have examined individually for 45 minutes each during that one-day visit. As a result of this type of fraudulent billing, Medicare paid Sponseller for that type of eye exam more than any other doctor in the United States in 2009.
United States Attorney Edward J. Tarver said, “Health care fraud is a cancer on the financial health of our nation. In many cases, such as with this defendant, it is committed by professionals who are well educated and highly regarded. Whether that fraud is perpetrated by an optometrist willing to claim that he worked the equivalent of five-and-a-half days during a one-day visit to a nursing home—like this defendant did—or a medical equipment supplier that bills Medicare without authorization, the ultimate injury is to the American taxpayer. The United States Attorney’s Office and its law enforcement partners will actively pursue those who abuse our country’s health care programs for financial gain.”
Derrick L. Jackson, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General for the Atlanta region, said, “Any time false claims are submitted for payment, our nation’s health insurance programs and beneficiaries suffer. Protecting precious Medicare funds remains a top priority for the Inspector General and our law enforcement partners.”
Sponseller faces a maximum penalty of five years’ imprisonment and a fine of up to $250,000, in addition to paying restitution. The date for Sponseller’s sentencing hearing has not yet been scheduled.
FBI Special Agents Paul Kubala and Jason Gustin, U.S. Attorney’s Office Investigator Kimberly Reinken, HHS-OIG Special Agent David Graupner, and IRS Special Agents Roger Garland and Jeffrey Hale participated in the investigation of this case. Assistant United States Attorney David Stewart is prosecuting in this case. For additional information, please contact First Assistant United States Attorney James D. Durham at (912) 201-2547.
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