Payers, Policy

Record $1B Medicare fraud? It’s Florida’s unofficial state sport

It’s the largest single criminal healthcare fraud case the Justice Department has ever brought against individuals.

Fraud electronic medical record fraud

Need more evidence that Medicare fraud is the unofficial state sport of Florida?

Friday, federal prosecutors unsealed an indictment against three Miami-area residents, charging the suspects with conspiracy, obstruction, money laundering and healthcare fraud estimated at $1 billion. If it sounds like a lot of money, it is.

“This is the largest single criminal healthcare fraud case ever brought against individuals by the Department of Justice,” Assistant Attorney General Leslie R. Caldwell said in a DOJ press release.

Philip Esformes, 47, operated a network of more than 30 skilled nursing and assisted living facilities in South Florida, according to DOJ. (Nursing Home Report compiled a partial list here.)

He is charged with Medicaid and Medicare fraud for providing “medically unnecessary” services to perhaps thousands of beneficiaries who did not qualify for federal reimbursement.

Esformes and the other two defendants, hospital administrator Odette Barcha, 49, and physician assistant Arnaldo Carmouze, 56, allegedly paid kickbacks to themselves for referring many of the same patients to other healthcare providers for similarly unnecessary services.

“In order to hide the kickbacks from law enforcement, these kickbacks were often paid in cash, or were disguised as payments to charitable donations, payments for services and sham lease payments,” the Justice Department charged.

Esformes has a prior record, according to prosecutors. DOJ said he paid $15.4 million in 2006 to settle federal civil healthcare fraud charges. Esformes and his father, Morris, settled unrelated kickback claims in 2013, the Chicago Tribune reported.

This was not enough of a deterrent. According to DOJ:

However, Esformes and his co-conspirators allegedly continued this criminal activity — adapting their scheme to prevent detection and continue their fraud after the civil settlement. The indictment alleges that the co-conspirators accomplished this by employing sophisticated money laundering techniques in order to hide the scheme and Esformes’ identify from investigators.

The FBI and the Department of Health and Human Services’ Office of Inspector General HHS-OIG were able to unravel the Medicare fraud scheme through data mining and forensic accounting, the Justice Department said.

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