Medicare Fraud earns Dr. Rene De Los Rios 235 months in Federal Prison. Comments by Ethics and Fraud Prevention speaker Chuck Gallagher

The following is a news release from the Department of Justice.  Please note – EVERY CHOICE HAS A CONSEQUENCE!  As an ethics and fraud prevention speaker to numerous governmental agencies including the FBI – it is clear that regardless of how clearly wrong choices like this may be, the fact remains that unless there are safeguards put in place to remove one of the three components that allow an ethics person to make unethical and illegal choices, we will continue to have frauds like this and the consequences that follow.

If you know of Dr. Rene De Los Rios and have insight into the doctors thinking…feel free to share your comments below!

WASHINGTON – Miami doctor Rene De Los Rios, 72, was sentenced today to 235 months in prison for his participation in a $23 million HIV injection and infusion Medicare fraud scheme , announced the Departments of Justice and Health and Human Services (HHS).

U.S. District Court Judge Joan A. Lenard of the Southern District of Florida also sentenced De Los Rios to three years of supervised release following his prison term and ordered him to pay a minimum of $11.7 million in restitution, jointly with his co-defendants.  The final amount of restitution will be determined at a later hearing.   On April 14, 2011, De Los Rios was convicted by a jury of one count of conspiracy to commit health care fraud and four counts of submission of false claims.  De Los Rios was remanded to the custody of the U.S. Marshals Service after his conviction and has been detained since that time.

According to evidence presented at trial and sentencing, De Los Rios worked at multiple fraudulent medical clinics and signed medical documents authorizing tests and treatments that were medically unnecessary or never provided.   The court found De Los Rios responsible for a total of $46 million in fraudulent billings to Medicare.

According to evidence presented at trial, De Los Rios was hired by the owner of Metro Med of Hialeah Corporation, an HIV infusion clinic that purportedly provided injection and infusion therapies to HIV-positive Medicare beneficiaries.   Evidence presented at trial established that De Los Rios ordered unnecessary tests, signed medical analysis and diagnosis forms, and authorized treatments to make it appear that legitimate medical services, including injection and infusion therapies, were being provided to Medicare beneficiaries at Metro Med.  However, the injection and infusion therapies were medically unnecessary and never provided.   De Los Rios also signed medical charts, often without seeing the patient, indicating that certain treatments were medically necessary, when, in fact, he knew they were not.

Evidence at trial established that De Los Rios diagnosed almost all of the patients at Metro Med with the same rare blood disorders, which the patients did not have, in order to ensure maximum reimbursement from Medicare.  The evidence at trial also showed that De Los Rios prescribed expensive medications, including Winrho, Procrit and Neupogen, to patients for the sole purpose of receiving reimbursement from the Medicare program.  From approximately April 2003 through October 2005, Metro Med submitted approximately $23 million in claims to the Medicare program for injection and infusion treatments that were not medically necessary and were never provided.  The Medicare program paid approximately $11.7 million in claims.

The owner and operator of Metro Med, Damaris Oliva, and three other individuals have each pleaded guilty for their roles in the Metro Med fraud scheme.   Oliva was sentenced in December 2010 to 82 months in prison.   Co-defendants Estrella Rodriguez, Jose Diaz and Lisandra Aguilera were sentenced to 57 months in prison, 54 months in prison and 70 months in prison, respectively.

Evidence at trial and sentencing also established that De Los Rios engaged in almost identical conduct at additional sham HIV injection and infusion therapy clinics in South Florida during the same time period.  At J&F Community Medical Center Inc.  and Rochris Medical Center Inc., De Los Rios prescribed the same medications that he prescribed at Metro Med to patients who he knew did not need them.

In a two-and-half-year period, De Los Rios made more than $587,000 in profits from the fraud schemes.

At sentencing, the court also found that De Los Rios obstructed justice by testifying falsely at his trial; that as a doctor, De Los Rios occupied a position of trust, which he violated; and that by prescribing medically unnecessary injections and infusions for HIV-positive patients, De Los Rios caused a reckless risk of serious bodily injury to those patients.

The court declared a mistrial in De Los Rios’ first trial in March 2011.

Today’s 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; John V. Gillies, Special Agent-in-Charge of the FBI’s Miami Field Office; and Special Agent-in-Charge Christopher Dennis of the HHS Office of Inspector General (HHS-OIG), Office of Investigations Miami office.

The case was prosecuted by Trial Attorney Joseph S. Beemsterboer of the Criminal Division’s Fraud Section and Robert J. Luck, Assistant U.S. Attorney for the Southern District of Florida.   The 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 operations in nine locations have charged more than 1,000 defendants and organizations that collectively have billed the Medicare program for more than $2.3 billion.  In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with the 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 .

YOUR COMMENTS ARE WELCOME!

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4 Responses to Medicare Fraud earns Dr. Rene De Los Rios 235 months in Federal Prison. Comments by Ethics and Fraud Prevention speaker Chuck Gallagher

  1. Unfortunatly, this kind of fraud practice is more common than not – and not just in Florida. Across the entitlement healthcare perspective, a number of studies have shown that only about 30 to 45 cents on the dollar actually go to pay for care, the rest get split – the split varies by study – between fraud and abuse and duplicated/unnecessary services. So about 66 cents on the dollar spent on health care is wasted.

    The simple fix to this is not prosecution – that is a necessary step to punish, but wastes even more federal money. The simple step is to federally mandate a full coordination of care and benefits across all available sources, with federal dollars being the payer of last resort.

    This was something that was recommended during the legislative process for “ObamaCare” and was rejected for some specific and spurious reasons. Full coordination of care and benefits would drastically reduce nationally waste and fraud, and help stop these kinds of activities in their tracks.

    FCOCB, would also have the added benefit of freeing more resources to pay for, or treat, more patients due to the reduction in duplication of services. Estimates of this range from 20% more capacity to 40% more capacity. Using the annual federal estimate for US care cost of 2.6 trillion, this could go a long way toward covering the cost of an effective safety net for the undereserved.

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  2. [...] Chuck Gallagher comments on a Medicare fraud case.  Mr. Gallagher is always a good read! He is a noted lecturer in the field of business ethics. [...]

  3. [...] Chuck Gallagher comments on a Medicare fraud case.  Mr. Gallagher is always a good read! He is a noted lecturer in the field of business ethics. [...]

  4. Sylvia DuBock says:

    I am not surprised. My late husband was a patient of Dr. Rene de los Rios back in the early 1990s…my husband had suffered 2 strokes by that time and was physically handicapped. He was totally dependent on me and we had 3 small children together. I kept asking Dr. de los Rios for a Handicapped Parking permit sign to clip on our car just so my husband would have easier access…if anyone ever needed one it certainly was my husband…he had fallen down walking to the store and was hospitalized for almost 2 weeks, broken facial bones, more medical problems…yet Dr. de los Rios would never facilitate his signature to obtain the permit. Patiently, I kept on and on at each monthly visit and finally Dr. de los Rios, in a vary rude and unprofessional way, told me the reason he could not was because Medicare would treat this as fraud…fraud??? my husband could hardly stand, let along walk…I terminated this “quack!!!” and had my husband change doctors…de los Rios did come to the house…which was one of the reasons we thought it was a good idea, but this doctor failed my husband in a very big way. I am so glad that he was sentenced…he should have treated his patients properly, instead he was just treating his own pocket…Karma!!!!

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