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Monday, May 23, 2016

Fraud Report-Criminals in the U.S. Healthcare System

Fraud Report U.S. Healthcare-Corporate Greed and Justice Intervention
Americans have been conditioned to view healthcare fraud as a crime perpetrated by Medicaid cheats, but the curtain is being pulled on corporate fraud, which costs healthcare consumers so much more than welfare opportunists.  This week, criminal trials begin for executives at two different companies, Allergan’s Warner Chilcott unit, a pharmaceutical company and Johnson and Johnson, a medical device manufacturer, at the federal court in Boston.[1] The justice department decided the billions in corporate fines were not sufficiently deterring corporate misconduct in healthcare and has started to pursue criminal charges for white collar criminals who here-to-for thought they could pay a fine and walk. The individuals in the chart below have been indicted by a federal grand jury and will stand trial:
Corporate Fraud
Pharmaceutical Industry
Allergan subsidiary Warner Chilcott has already plead guilty to healthcare fraud and paid a $125,000,000 fine
W. Carl Reichel, ex-president of Warner Chilcott
Kickbacks (bribes) to healthcare providers
Applies to Atlevia, for osteoporosis and other drugs
Medical Device Industry
Johnson & Johnson subsidiary, Acclarent
William Facteau, former CEO and Patrick Fabian, former Vice President of Sales
Promoting unauthorized use of a sinus opening device (fraud) and securities fraud for nondisclosure
Spiking sales for a balloon device used for sinus procedures by promoting it as a steroid delivery device to inflate share price
(Division April 15, 2016)[2]
Fraud Report- Criminals in our Healthcare system
Due to the plethora of convicted criminals in healthcare, each table will show the crime by classification for 2016 and is all drawn from the U.S. Health & Human Services Fraud Report. (Services 2016) Also, only individuals working in the healthcare industry who committed the crimes are listed, not other nefarious opportunists. Also, Stark Law violations, which create fines for hospitals which have privileged financial relationships with community based physicians are not listed because that would generate an entire article.
Drug Dealers
Prescription Drug Fraud, money laundering, conspiracy
Kentucky Anesthesiologist
Convicted May 12th, Jaime Guerrero; sentenced to 100 months (8.3 years) in prison
Unlawful distribution of a controlled substance
Prescribing Hydracodone without medical necessity
Prescription Drug Fraud, money laundering
Drs. Alan Summer, Azad Khan, Keyhosrow Parsia
Indicted May 11th
Unlawful distribution of a controlled substance
Unlawful sale of Klonopin and Suboxene for cash
Fraudulent prescriptions
Pennsylvania, Dr. John Terry
Sentenced-plea bargained January 5th
Fraudulent prescriptions
Unlawful prescriptions for oxycodone
Fraudulent prescriptions worth $20,000,000
California, Dr. Kenneth Johnson
Sentenced to a 108th months (9 years) prison term January 6th
Fraudulent prescriptions written out of sham medical clinic in Glendale
Pre-signed thousands of prescriptions
Fraudulent prescriptions
West Virginia, Dr. Jose Jorge Abbud Gordinho
Plead guilty January 7th
Fraudulent prescriptions
Unlawful prescriptions for hydrocodone
Conspiracy to distribute narcotics
New York, Dr. Kevin Lowe
Found guilty May 4, 2015, sentenced January 11, 2016 to 144 months in prison (12 years)
Owned Astramed, a clinic in the Bronx, NYC
Unlawful distribution of oxycodone

Medicare Fraud-Overbilling or False Claims
These criminals are listed in descending order from the beginning of 2016
Defrauding Medicare of $4,500,000
Hovik Simitian, sentenced to 78 months (6 ½ years) in prison, January 2nd
Included 3 clinics: Columbia Medical, Safe Health, and Life Care
Fraudulent claims
Over billing Medicare $7,800,000

Nashville Pharmacy Services, LLC
Kevin Hartman, majority shareholder agreed to the plea

Over billing for Aids and HIV medications
Fraudulent claims of $70,000,000
Transportation Services Providers Inc. Damian Mayol, sentenced January 8th
Included 3 clinics and involved mental health patients
Involved kickback payments and billing for unnecessary services
Fraudulent claims, $63,000,000
Nery Cowan plead guilty January 14th, sentenced on March 25th to 60 months (5 years) in prison
Ms. Cowan was a consultant and Medicare biller for Greater Miami Mental Health Center
Directed kickback payments and received a percentage of Medicare reimbursements
Fraudulent claims, $375,000,000
Patricia Akamnonu, RN sentenced to 10 years and ordered to pay $25,000,000 in restitution on January 19th
Founder of Ultimate Care Home Health Services Inc.
Fraudulent claims for home health care services
Fraudulent claims, $57,000,000, healthcare fraud, wire fraud, conspiracy
Khaled Elbeblawy, convicted of fraud, January 22, sentenced to
Jem Home Health Care, Healthy Choice Home Health Care, Willsand Home Health Agency Inc.
Fraudulent claims for home health care services

Medicare Fraud-Unnecessary Medical Services
False Claims
Virginia, Bostwick Laboratories
Dr. David G. Bostwick, sentenced January 8th, ordered to pay $3,700,000 fine
False claims for unnecessary services and kickbacks to physicians
Unnecessary cancer detection services
False Claims
Nationwide rehabilitation services provider, Kindred Rehabcare
Company Agreed to pay $125,000,000 to the government on January 12th
False claims for skilled nursing facility services
False claims for unnecessary rehabilitation services
False Claims
 Illinois, convictions for officers of Mobile Doctors had already been procured
Dr. Banio Koroma, Mobile Doctors convicted of federal fraud, on January 25th, sentencing set for June 6th
Certified patients were home bound when they were not
False claims for unnecessary home health care services
False Claims for $1,500,000
Amalya Cherniavsky, owner of California Medical Equipment Supply Company
False claims for unnecessary services
Kickbacks for prescriptions for unnecessary medical equipment
As you may have surmised, there are so many fraud cases, I have only been able to illustrate the month of January 2016 in this article, so certainly this topic needs revisiting on a regular basis. Let’s all give a big thank you to the hard working folks at the Medicare Fraud Strike Force-your government dollars working effectively to cut fraudulent waste in the healthcare system. The next time you hear someone complaining about all of the focus on fraud in the healthcare system and how it is unnecessary, feel free to refer them to this handy summary. And this is the healthpolicymaven signing off wishing you fully informed consent in all of your health care decision making.

The healthpolicymaven is a trademark of Roberta E. Winter and Praevalere Inc. Feel free to share this article virally. Roberta Winter is the author of

Works Cited

Division, Federal Drug Agency-Enforcement. April 15, 2016. Former Acclarent, Inc. Executives Charged with Securities Fraud and Crimes Related to Sale and Distribution of Medical Devices. United States Department of Justice Proceeding, U.S. Health and Human Services, Boston: U.S. Department of Health and Human Services. Accessed May 23, 2016.
Loftus, Peter. 2016. "Ex-Health Executives Go on Trial." Wall Street Journal, May 23: B1-B2.
Services, U.S. Health & Human. 2016. "Healthcare Fraud Report." Health & Human Services. Accessed May 23, 2016.

[1] Loftus, Peter. 2016 “Ex-Health Executives Go On Trial.” Wall Street Journal, May 23: B 1-2


Connie Simoni said...

It's shocking to see so much fraud and it appears to be across the board from executives to doctors to nurses to insurance men and women. Its very frustrating to hear of this when so many people with insurance struggle trying to pay co pays for prescriptions that wouldn't be so expensive if there wasn't so much fraud. It's a problem we all have to face.

Franz Porzsolt MD PhD said...

When I used to work as Medical Oncologist and trained in Evidence-based Medicine I detected a permanently growing lack of efficiency in health care. The few cases of detected fraud could not explain the huge amount of mistakes. The data I collected in the last 20 years lead into the conclusion that it is important to identify the BAD guys but even much more important to identify the reliable doctors and nurses. We, our friends and neighbours have to know today in whom we can trust. The detection of the bad takes years and sometomes decades. The damage is usually history and irreparable.
We may consider a system in which patients play a central role in outcomes research. Patients communicate the outcomes of care and talk about nice nurses and good doctors. Why are hospital managers not interested in the standardized collection and Evaluation of this information?

healthpolicymaven said...

My intent is to continue to focus on the fraud issue and through that process, reveal the organizations which are the best, honest purveyors of quality healthcare. They are out there, like the Mayo Clinic and Virginia Mason, but there are other smaller organizations which are doing a quality job. And Kaiser, despite being assailed, delivers high quality healthcare across the board. The purpose of this column is to increase the engagement of the public in understanding important criteria to evaluate a health system, to inform their decisions for procedures and policy making. Through consumer education and outreach we can systemically work toward necessary reforms. And finally, because Americans pay so much for their health care (and I am not just talking about insurance premiums) they are keen to discern value and jettison poor performers.

Akansha Singh said...
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vanaja N said...
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