Healthcare billing fraud: 12 recent cases

From a former NBA player pleading to orchestrating a $5M health insurance scheme, to the conviction of a medtech CEO in a $77M COVID-19, allergy testing scheme, here are 11 healthcare billing fraud cases Becker's has covered since Aug. 25. 

1. NewYork-Presbyterian/Queens Hospital settles federal healthcare fraud allegations for $2.5M

NewYork-Presbyterian/Queens Hospital agreed to pay $2.5 million Sept. 14 to settle allegations that a former physician performed and billed for unnecessary procedures. The services involved the replacement of implantable cardioverter defibrillator (ICD) pulse generator batteries, which the physician repeatedly replaced before they reached their elective replacement interval. The hospital submitted claims for payment to federal healthcare programs for these procedures. The physician's conduct was discovered as a result of an internal investigation conducted by the hospital.

2. Massachusetts nurse pleads guilty in $100M fraud scheme

Winnie Waruru, a licensed practical nurse at Chelmsford, Mass.-based Arbor Homecare Service pleaded guilty Sept. 8 to her role in a scheme to defraud MassHealth and Medicare out of at least $100 million by committing fraud and paying kickbacks to get referrals.  Arbor billed MassHealth for Ms. Waruru's skilled nursing visits, many of which she did not perform.

3. Mother, daughter pharmacy owners accused of $12M Medicare fraud scheme

Sunrise, Fla.-based Aviva Care Pharmacy owners Mirosis Gonzalez and her daughter Berioska Sosa were indicted Sept. 9 for allegedly paying kickbacks and bribes to marketing and telemedicine companies in exchange for referrals of Medicare beneficiaries, as well as doctors’ orders and prescriptions.

4. Florida medical equipment company owner gets 87 months in fraud scheme

Daniel Cazola, owner of Miami-based Myers Professional Services, was sentenced Sept. 8 to more than seven years in prison after admitting he purchased lists of Medicare patients and then directed a biller to submit fraudulent claims to Medicare for durable medical equipment that was not prescribed by a doctor, not medically necessary and was not supplied to any legitimate patient or recipient. 

5. Iowa plastic surgeon to pay $800K to resolve billing fraud claims

Des Moines, Iowa-based plastic surgeon Ronald Bergman, DO, agreed to pay $800,000 to settle allegations he submitted claims to Medicare and Medicaid in his own name that were performed by others; he also allegedly submitted claims to Medicare for medically unnecessary and unreasonable applications of skin substitute products. 

6. Medtech company president convicted in $77M COVID-19, allergy testing scheme

Mark Schena, president of the medtech company Arrayit Corp, was convicted Sept. 2 of submitting fraudulent claims to Medicare and private insurance for medically unnecessary allergy tests that did not actually diagnose allergies and paying illegal kickbacks to marketers to obtain patient blood specimens. He reportedly billed some commercial insurers more than $10,000 a test and falsely claimed he was on the Nobel Prize shortlist. 

7. Former Yale New Haven Health worker pleads guilty in embezzlement scheme

Former Yale New Haven (Conn.) Health patient care associate Lamont Bethea pleaded guilty Sept. 1 to fraud offenses in connection with two separate criminal schemes. One scheme involved embezzling payroll funds and the other involved forged checks.  

8. Healthcare CEO, physicians sentenced to prison for $27M fraud

Thirteen people involved in a $27 million healthcare fraud scheme, including Novus CEO Bradley Harris, were sentenced to a combined 84 years in federal prison for their roles in a fraud scheme involving the Dallas-based hospice agency. The defendants defrauded Medicare by submitting false claims for hospice services, providing kickbacks for referrals and violating HIPAA to recruit beneficiaries. Novus employees also dispensed controlled substances to patients without the guidance of medical professionals.

9. Texas medical director convicted in Tricare fraud scheme

Adar Group Outpatient Toxicology Medical Director Sekhar Rao, MD, was convicted by a federal grand jury for engaging in a scheme to defraud Tricare by authorizing toxicology and genetic testing for beneficiaries without seeing, speaking to or treating them.

10. Florida chiropractor gets 4 years in prison for $20M fraud scheme

Boca Raton, Fla.-based chiropractor Jonathan Rouffe was sentenced Aug. 29 to four years in prison for a $20 million scheme that resulted in more than $10 million in payments from both Medicare and the Civilian Health and Medical Program of the Department of Veterans Affairs

11. Former NBA player orchestrated $5M health insurance fraud

Former NBA player Terrence Williams pleaded guilty to orchestrating a scheme to defraud the NBA Players' Health and Welfare Benefit Plan. The scheme involved more than 18 former NBA players, a dentist, a physician and a chiropractor.

12. Missouri physician gets 1 year in prison for fraud scheme

Missouri physician Dr. Abdul Naushad was sentenced to one year in prison Aug. 25 for a scheme that involved injecting patients with cheaper unapproved drugs on more than 1,000 occasions spanning nearly a decade.  

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