Leonard Langman, M.D. Pleads Guilty to Medicare and Health Care Fraud – What motivated his behavior?

For those physicians who provide health care to patients who are covered by Medicare, Workman’s Comp. or other similar types of services, has it become so restrictive that the reduced fees earned is forcing physicians to turn to illegal activities to compensate?

I suspect that as you read this your first reaction is What?  What a reach and crazy question…  But, before your read the account of the doctor who could receive 10 years in Federal Prison below – think about what comes together to create a fraud.  As a business ethics and fraud prevention speaker, I see, all to often, that when three things come together: (1) Need; (2) Opportunity and (3) Rationalization – it creates the PERFECT STORM for fraud.  To be clear, just because those three things are present does not mean that Fraud will occur, rather it means that the conditions are right for the ethical person to make the unethical choice that can lead to illegal activities and fraud.  As I speak to groups internationally the significant question that comes up is not what happened – that is generally evident by the facts, but rather what motivated the perpetrators behavior in the first place?

I don’t know what motivated Leonard Langman, M.D. but you can take to the bank (not literally as Dr. Langman did) that there was some need that was the spark that motivated his behavior.  The question is what?  Read the US Attorney’s news release below for details and perhaps you can comment on his motivation…

PRESS RELEASE

BROOKLYN NEUROLOGIST PLEADS GUILTY IN HEALTH CARE FRAUD SCHEME

WASHINGTON – Leonard Langman, M.D., a neurologist who owned and operated a Brooklyn, N.Y., medical clinic pleaded guilty today for his role in a scheme to defraud Medicare; the U.S. Department of Labor, Office of Workers’ Compensation Programs (OWCP); the New York State Workers’ Compensation Board (NYS-WCB); the New York State Insurance Fund (SIF) and various private health insurance carriers, announced the Departments of Justice and Health and Human Services.

Dr. Langman pleaded guilty before U.S. District Judge Kiyo A. Matsumoto in Brooklyn to one count of health care fraud.

According to court documents, from January 2006 to December 2009, Dr. Langman caused false and fraudulent claims to be submitted to Medicare, OWCP, NYC-WCB, SIF and others.  Langman submitted claims for services that were not provided; misrepresented the services he provided by billing for a level of service higher than that which he performed; double-billed different health care benefit programs for the same service provided to the same beneficiary; and billed for services purportedly performed when he was out of the country.

At sentencing, Dr. Langman faces a maximum sentence of 10 years in prison.  Sentencing is scheduled for Dec. 2, 2011.

The guilty plea was announced by Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division, U.S. Attorney Loretta E. Lynch for the Eastern District of New York and Special Agent-in-Charge Thomas O’Donnell of the Department of Health and Human Services, Office of Inspector General (HHS-OIG).

The case is being prosecuted by Trial Attorney James Hayes of the Criminal Division’s Fraud Section.  HHS-OIG, the U.S. Postal Service, Office of Inspector General and the New York State Workers Compensation Board, Office of Inspector General conducted the investigation.  The case 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 Eastern District of New York.

Since their inception in March 2007, Strike Force operations in nine locations have charged more than 1,000 defendants who collectively have falsely billed the Medicare program for more than $2.3 billion.  In addition, the HHS 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.

If you have insight into this case…please share your thoughts.

YOUR COMMENTS ARE WELCOME!

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!

Billing for false claims – come on! John D. Kristofic, MD Sentenced to Prison for Health Care Fraud

Billing for false claims – somehow I don’t think that was taught in Medical school.  Likewise, it’s hard to imagine how someone could envision that behavior to be moral or ethical, yet every day people justify or rationalize behavior and, as I say in my ethics presentations, every choice has a consequence.  Dr. John D. Kristofic will be spending time in prison – having time to think about his choices.

On May 5, 2010, Dr. John D. Kristofic, age 62, a resident of Allegheny County, was sentenced in federal court in Pittsburgh, Pennsylvania, to one year in prison to be followed by three years of supervised release on his conviction of health care fraud.

Between January of 2003 and August of 2008, Dr. Kristofic submitted fraudulent claims to Medicare and to his patients’ health insurers for medical services which he never rendered.  During that time, Dr. Kristofic was paid in excess of $1 million for the fraudulent claims which he had submitted.  As part of the plea, Dr. Kristofic paid $3,303,188 to the government as restitution for the fraudulent claims and the costs of the government’s investigation.

Fortunately for Kristofic – his “other” choices helped to mitigate his sentence as the recommended range of sentencing under the United States Sentencing Guidelines was 33 to 41 months of imprisonment. However, Judge Ambrose varied from that recommended range based on Dr. Kristofic’s history of working as a volunteer, including his history of treating homeless people in the Pittsburgh area and providing free medical care to needy persons in Haiti.

YOUR COMMENTS ARE WELCOME!

Medical Device Manufacturers (and Sellers) Take Note – Atricure to Pay U.S. $3.76 Million to Resolve Medicare Fraud Allegations

Quite interesting…  I had a discussion with a prospective client the other day who was sharing the need for firms – especially those in the Medical field – to operate ethically and know the rules when it comes to sales and ‘inducement’!  “It is clear,” he stated, “that firms need to take proactive actions to make sure that they not only operate within the law (as they understand it), but take affirmative actions to demonstrate their intent to operate in an ethical/legal environment.  As I was considering a fraud prevention presentation for this firm, then two days later this crosses my desk…

According to the Justice Department – Atricure Inc., a medical device manufacturer, has agreed to pay the United States $3.76 million to resolve civil claims in connection with the alleged promotion of its surgical ablation devices.  Surgical ablation devices use focused energy to create controlled lesions or scar tissue on a patient’s heart or other organs.

The settlement resolves allegations that the West Chester, Ohio-based company marketed its medical devices to treat atrial fibrillation (the most common cardiac arrhythmia or abnormal heart rhythm), a use that is not approved by the U.S. Food and Drug Administration (FDA). Atricure also allegedly promoted expensive heart surgery using the company’s devices when less invasive alternatives were appropriate, advised hospitals to up-code surgical procedures using the company’s devices to inflate Medicare reimbursement, and paid kickbacks to health care providers to use its devices. The United States asserted that by engaging in this conduct, Atricure knowingly violated the Food, Drug, and Cosmetic Act and caused the submission of false and fraudulent claims in violation of the False Claims Act.

The allegations were made against Atricure in a lawsuit filed under the qui tam or whistleblower provisions of the False Claims Act, which permit private citizens, called “relators,” to bring lawsuits on behalf of the United States and receive a portion of the proceeds of any settlement or judgment. The relator will receive a total of $625,000 as the statutory share of the current settlement.

NOTE: With opportunities for whistleblowers to gain personally from a settlement…it should be clear that challenges to operating actions come from many angles.  Some companies consider this a cost of doing business, but when the settlement hits (assuming there is no prosecution) the use of the equipment changes and people tend to run from issues that have a negative legal implication.

“The misuse of medical devices has the potential of exposing patients to dangerous procedures and taxpayers to payment of unwarranted claims against Medicare,” said Tim Johnson, United States Attorney for the Southern District of Texas. “This settlement demonstrates the government’s commitment to maintaining safe and affordable health care for its citizens.”

This settlement is part of the government’s emphasis on combating health care fraud. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover approximately $2.2 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 have topped $3 billion.

COMMENTS ARE WELCOME!

Dr. Janet Johnson Hunter Pleads Guilty to Medicare Fraud…what was she thinking?

For more than three years, Janet Johnson-Hunter, a licensed medical doctor and former owner/manager of a private ambulance transportation company, committed fraud.  Johnson-Hunter, late this past year, pled guilty to conspiring to conceal material facts in connection with the delivery of payment for health care benefit, items and services according to a news release from the US Attorney’s office.

Johnson-Hunter changed medical records and ordered employees to change records to indicate patients’ needs to ride in an ambulance, when they did not, in order to be reimbursed by Medicare or Medicaid, according to a federal criminal information complaint was filed Nov. 30.   According to numerous EMT’s and billing staff, Johnson-Hunter, directly and through subordinates, directed employees to re-write medical records which indicated that patient-beneficiaries could sit upright, stand, walk or ride in a wheelchair.  The loss to Medicare/Medicaid = $400,000.

WHAT WAS SHE THINKING?

First I should say, it is not for me to point the finger.  I am not here to pass judgment, that is not mine to pass.  Rather, I’d like to explore the WHY this would or did happen.  As a business ethics speaker, I know that EVERY CHOICE HAS A CONSEQUENCE!  I have lived those words and spent time in federal prison as a result of my past misdeeds.  While I am not proud of that fact, it is a fact nonetheless.  The one thing I am able to do, as a result, is look at choices from a unique perspective.

NEED:  I can’t identify the need directly.  One would assume that to change records in order to increase billing or reimbursement from Medicare would driven by a need for money.  Seems obvious, but Bernie Madoff surely did not need the money, yet he effected one of the largest frauds in US history.  So what’s the need here?  Perhaps those who know Dr. Johnson-Hunter could help with that piece of the puzzle.  FEEL FREE TO COMMENT.

OPPORTUNITY:  It is of little doubt that any system can be manipulated.  If one person can take advantage of a system, one might say that there is a material weakness.  In this case, Janet Johnson-Hunter did not do this alone.  Rather, she used her power and influence to cause others to change records and thus deceive Medicare.  Now…a fair question is: will the Federal Government go after those who admitted to changing records or have they been given immunity from prosecution.

RATIONALIZATION:  This area is most troublesome.  Here’s a reality check…a 50 year old female medical doctor knows better.  You can’t live for half a century and earn a medical degree without having some clue that choices have consequences.  This is especially true when you involve others in the fraud.  You have to know that someone somewhere is going to reveal the truth.

Why would Dr. Janet do this..?  Perhaps that will come out as people comment.  For now, let me restate the obvious:  EVERY CHOICE HAS A CONSEQUENCE.  When you hear the words, “You will reap what you sow” let me state from experience – THEY ARE VERY TRUE.

Likely, Dr. Janet will spend time in federal prison (as did I some 15 years ago for a similar crime).  Prison is no fun as Dr. Janet will soon find out.  But, the question she has to face now, especially now since her misdeeds are brought to light, is what choices will she make now that prove redemptive in the future.

A wise man once said to me:  “You’ve made a big mistake, BUT YOU ARE NOT A MISTAKE!  The choices you make today will define your life in the future and the legacy you leave for your two sons.  MAKE THOSE CHOICES WISELY!”

Comments are welcome

Kansas City Internal Medicine doctors turn away Medicare enrollees, sparking ethics debate

Here’s a question for you: If you had a service to provide — and someone asked you to provide it for free, or at a radically reduced price — would you do it?

No, right?

Now try this on for size: If you were a doctor, and someone asked you to provide a service at a rate that didn’t reimburse you for the total cost of care, would you do it?

In nearly every line of business, one maxim holds true: “If you can’t pay, we don’t play.” So, why should doctors be viewed any different?

That’s the question doctors at Kansas City Internal Medicine, the largest private group practice in Kansas City, Mo., have been asking. For now, most of these doctors, who count 65 percent of their 70,000 active patients age 65 or older, have decided to stop accepting walk-in Medicare enrollees.

Dr. David Wilt, an internist at the group, tells CNN: Medicare doesn’t reimburse physicians enough to cover the cost of care. Matters will only get worse, he adds, if a 21 percent cut in Medicare payments to physicians takes place in 2010.

Should physicians be allowed to turn away patients because their funding source is being reduced? On the flip side, does the government have the right in a free-market economy to dictate payment terms to physicians for the performance of services?

Share your comments here.

Health Care Fraud Earns Irene Anderson A 46 Month Federal Prison Sentence! Fraud Prevention Expert Chuck Gallagher Questions Motives…

What motivates fraudulent behavior?  Are fraudsters basically bad or do good people make poor choices which leads to fraud?  These are questions seem to asked daily as new reports surface of indicted or sentenced fraud.

Seems that Irene Anderson, 45, of Wylie, Texas, was sentenced to 46 months in federal prison and was also ordered to pay $2,276.622.31 restitution,  forfeit a 2006 Hummer, a 2002 Suzuki and $8500 in cash that was found in her car when she was arrested on April 18, 2008.   Not only is a 46 month prison sentence significant, but returning to society as a convicted felon and owing over $2 million in restitution would be an obstacle that would seem insurmountable.

According to the US Attorney’s news release:

Beginning in February 2005 and continuing until May 2008, Anderson operated a scheme to defraud the U.S. Department of Health and Human Services and Medicare by applying for and obtaining a Medicare provider number for her home health agency, New Dimension, falsely representing that New Dimension was owned by “Iya E. Edwards.”

Iya Edwards, dba New Dimension was issued a Medicare provider number in March 2005 and from approximately March 9, 2005 to April 21, 2008, Anderson billed Medicare for services using that number. Throughout this period, Anderson continued to falsely represent to Medicare that the owner of New Dimension was Iya Edwards rather than Anderson, causing Medicare to pay New Dimensions a total of $1,188,698.74 because of her scheme. Anderson also fraudulently obtained in excess of another $1 million in Medicare funds paid to AG Total Care for home health visits that Anderson never made. These payments are included in the Court’s restitution order of $2.2 million.

According to a Fox News report at sentencing, “Irene Anderson sobbed in federal court as she pleaded for mercy. The Nigerian national told Judge Jane Boyle she was just trying to make a better life for her family. But the judge said she has seen few government scams involving this much money.”

In order to effect a fraud three components must be present:  (1) need, (2) opportunity and (3) rationalization.  It appears from Irene’s comment that her rationalization was creating a better life for herself and family.  The question however is why would she feel that theft thru fraud is the appropriate way?  She was reported as a Nigerian national.  Is it possible that based on her background that fraud is an acceptable method of getting ahead?

Every choice has a consequence.

There is a difference between making a bad choice and choosing to intentionally do wrong.  In this case there appears to be no indication of anything other than intentionally doing wrong.  This goes beyond unethical behavior to down right fraud.  Not only did Irene get an active prison sentence, but there had to be other casualties of her actions.  From wanting to help her family to spending time away from them in prison, one wonders the how and why of such an action.

However, so as not to sound judgmental – I openly admit that I did the same thing.  I made choices that had painful consequences and left a scar on my life that will never be forgotten.  Yesterday I had the privilege to speaking to a convicted felon who was recently released from prison.  I shared with her something that has sustained me on my journey following:  The choices you make today will define your life in the future.  Choose wisely!  We can elect to be a victim and be defined by our past or we can make different choices and create a life moving forward that is empowering – not only to ourselves but to those we touch.

Perhaps Irene will learn from her past choices and make those that will be uplifting in the future.

YOUR COMMENTS ARE WELCOME!