Friday, February 4, 2011

Top Ten Most Wanted for Health Care Fraud

As an advocate and caregiver, you must be on the watch for insurance, Medicare and healthcare fraud.  

Advocates and caregivers should examine and organize every medical bill, insurance statement and Medicare EOB.  

In my experience, the most common place where fraud is committed is in the area of Durable Medical Equipment (DME).  This includes everything from rented walkers and portable toilets (yes, you rent those things) to oxygen.

The most egregious example for me was a Request for Equipment that was contained the signature of a Duke University Medical physician and accompanying Medicare EOB indicating that Apria DME supplier was reimbursed by the US Federal Government for very expensive equipment that my dad never received.  

Although I reported the error, years later when my dad needed the equipment, the claim was disallowed because the fraudulent claim still appeared on the Medicare records.

The United States Department of Health and Human Services, Office of Inspector General is entrusted with the duty to prevent, investigate and prosecute Health Care Fraud.

As of the date of this posting, the current "Top Ten" are listed below.  
In all, the OIG is seeking more than 170 fugitives on charges related to health care fraud and abuse.

Carlos Benitez
Jose Benitez
Caridad Gullarte
Clara Gullarte
Leonard Nwafor
Luis Benitez
Dr. Steven Moos (captured)
Reynel Betancourt (captured)
Susan Bendigo
Eduardo Moreno

OIG Fugitives: “The Benitez Brothers”: Carlos Benitez, Luis Benitez, Jose Benitez

  • Carlos, Luis, and Jose Benitez, commonly referred to as the "Benitez Brothers," allegedly schemed to submit false and fraudulent claims to Medicare, pocketing approximately $110 million from Medicare, according to a Federal indictment.
  • The Benitez brothers owned and directed a string of medical clinics in the Miami area, purportedly providing infusion treatments to HIV-infected Medicare beneficiaries. But the medication the brothers provided to patients either was allegedly medically unnecessary or was never actually administered.
  • The brothers allegedly paid kickbacks to patients in exchange for the patients’ Medicare information, which they then used to submit false claims to the Federal Government for reimbursement.
  • More than 20 co-conspirators of the Benitez brothers have been charged in the Southern District of Florida with involvement in the HIV-infusion conspiracy. Most of them have pleaded guilty or have been convicted by a jury. A physician involved in the conspiracy was sentenced to a record-setting 30 years in prison.
OIG Fugitive: Dr. Steven Moos
  • Dr. Steven Moos is charged with drug possession, fraudulent Internet marketing, and child endangerment.
  • Formerly a general practice physician in Oregon, Moos lost his medical license after he repeatedly prescribed numerous prescription drugs over the Internet, despite warnings from the State medical authorities to stop such practices.
  • According to the Oregon Board of Medical Examiners, Moos prescribed drugs and refilled prescriptions without physically examining patients or obtaining health record information from them or their primary care providers.
  • After his medical license was revoked, Moos allegedly continued to practice medicine and prescribe drugs and made false statements on a Drug Enforcement Administration registration renewal application to conceal the fact that he no longer had a medical license to prescribe drugs, according to the indictment.
  • The Federal indictment stated that in the summer of 2002, Moos allegedly ordered misbranded drugs (including human growth hormone) from China. The drugs did not have adequate directions for use or warnings and other required information.
  • In February 2010, Moos was arrested and found guilty in the United Arab Emirates (UAE) of impersonating a physician and performing surgery in his villa. Sentenced to 2 months in prison, he also faces other charges in another part of UAE. U.S. authorities are working with UAE officials to bring Moos back for trial in the United States.

OIG Fugitives:Clara Guilarte, Caridad Guilarte, and Reynel Betancourt (CAPTURED)

  • Clara and Caridad Guilarte and Reynel Betancourt allegedly defrauded Medicare of nearly $4.3 million (and submitted $9.1 million in false and fraudulent claims), according to a Federal indictment. On November 30, 2010, authorities captured Betancourt in the Dominican Republic and subsequently sent him to the United States; the Guilarte sisters are still at large.
  • OIG is tracking down the Guilarte sisters in connection with the operation of the Dearborn Medical and Rehabilitation Center (DMRC) an infusion therapy clinic in Michigan. OIG alleges that the Guilarte sisters set up and operated the clinic where Betancourt was an employee.
  • All three fugitives allegedly committed health care fraud, conspiracy, and money laundering. The trio allegedly recruited and paid cash and other inducements to Medicare beneficiaries to visit DMRC and sign forms indicating that they received legitimate medical services, including injections and infusions of expensive medications, although the services allegedly were never provided.
  • All three are originally from Cuba: Clara Guilarte is a U.S. citizen, and both Caridad Guilarte and Betancourt are permanent U.S. residents.
OIG Fugitive: Susan Bendigo
  • Along with her co-conspirators, Susan Bendigo, who was born in the Philippines, is accused in a Federal indictment of billing Medi‑Cal, California's Medicaid program, for $17.1 million, collecting $10 million, about half of which came from the claims she submitted for services she provided with unlicensed staff.
  • A registered nurse, Bendigo was director of nursing for a company that provided nurses for home health agencies. Investigators say that from May 2004 through May 2007, she sent unlicensed nurses to treat patients under Medi‑Cal, even though she knew that Medi‑Cal required licensed nurses to perform the work.
OIG Fugitive: Leonard Nwafor
  • Through his durable medical equipment (DME) company, Pacific City Medical Equipment, Nwafor and his co-conspirators billed Medicare for $1.1 million and collected $525,000 in fraudulent claims for equipment such as motorized wheelchairs, scooters, and hospital beds for beneficiaries, according to a Federal indictment.
  • Based in the Los Angeles area, Nwafor used physicians’ Unique Provider Identification Numbers to bill Medicare for the equipment, even though those doctors did not examine Nwafor’s clients.
  • OIG investigated Nwafor
  • In the fall of 2008, a jury convicted Nwafor of conspiracy and health care fraud. He was to be sentenced in January 2009, but failed to show up in court. In March 2010, he was sentenced in absentia to 9 years in Federal prison and ordered to pay back more than $525,000 to Medicare.
OIG Fugitive: Eduardo Moreno
  • According to an April 2007 Federal indictment, Eduardo Moreno allegedly stole hundreds of thousands of dollars from the Medicare program, submitting false and fraudulent claims for durable medical equipment (DME) “and related health care benefits, items and services” that were medically unnecessary.
  • Moreno used a “straw owner” and other methods to hide the money and property he obtained through these fraudulent schemes, the indictment alleged. (A straw owner is an individual who maintains the appearance of owning property in order to disguise the identity of the real owner.)
  • He was arrested by the Miami Police Department on an open warrant. He failed to appear in court and his current whereabouts are unknown.
Be proactive - watch out for your own elderly and those for whom you care.  In addition, I recommend that you watch out for your neighbors.  I have known my elderly next door neighbors since I was 4 years old.  

Today both husband and wife are disabled (stroke victim and Alzheimer's) and are living in their own home.  Periodically, I make contact with their home health workers and re-introduce myself, ask if there is anything I can do and thank the ladies for their kindness.  

I am keenly aware that there are beautiful, kind people in this world.  However, I am not so naive to think that, in these desperate times,  the elderly and disabled cannot be victimized. Neighbors and friends must not presume the elderly are safe simply because a home health worker drops by everyday.

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