Image Source: huffingtonpost.com
Image Source: huffingtonpost.com

[box type=”default” size=”large”] Fraudulent schemes such as false billings uncovered [/box]

CHICAGO – A home care nurse would visit an elderly patient once a month but would ask her patient to sign four forms showing she visited the patient four times a month.

Although Medicare law says only 65 years old or older can benefit from the program, the home care agency owned by the nurse, Zenaida Dimailig, encouraged “55 years old or older” to be her patient.

Because Medicare patients are supposed to be homebound, Dimailig, who is also president of Berzen Home Care Services in Glenview, Illinois from April 17, 2006 and in Lincolnwood, Illinois from July 1, 2012, had instructed her patients to tell their primary-care physicians that they were taking public transport.

These are some of the ways Filipino-American nurse Dimailig allegedly circumvented the Medicare law, which provides free or below-cost healthcare benefits to, among others, persons 65 years old and older, younger people with disabilities and people with end-stage renal disease. Individuals who receive Medicare benefits are often referred to as Medicare beneficiaries.

Dimailig is one of 10 Filipinos indicted in Illinois for Medicare fraud and one of the defendants in 105 indictments announced jointly by United States Attorney General Loretta E. Lynch and Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell. The cases were filed in 17 districts against 243 individuals, including 46 doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes (false billings) involving approximately $712 million.

In a nationwide Medicare Fraud Strike Force operation, the Centers for Medicare & Medicaid Services (CMS) also suspended a number of healthcare providers, using its suspension authority provided for in the Affordable Care Act.

The coordinated takedown is the largest in Strike Force history, both in terms of the number of defendants charged and lost amount.

Zachary T. Fardon, United States Attorney for the Northern District of Illinois in Chicago, announced the filing of charges against 13 defendants, mostly Filipinos. They were charged in four cases as part of the national campaign.

One case in Illinois, titled U.S. v. Janet Guerrero, et al., might have been an offshoot of a previous case filed by a whistle-blower, Adrienne Falk, also called a relator, director of nursing of Josdan Home Health Care or (JCH Home Health Care). Falkr filed a case against her employer, JCH Home Health Care, Donnarich Home Healthcare, and Josie Tinimbang, owner of Donnarich Home Healthcare, in 2011, but these home healthcare businesses continued to operate until these were shut down in March 2014.

The hearing of the case filed by Falk against Tinimbang and Josdan and Donnarich Home Healthcare is scheduled on Aug. 18, 2015 before Judge Amy St. Eve of the Northern District of Illinois in Chicago.

Tinimbang, resident of Cook County, Illinois until June 2012, owner and operator of Donnarich, Josdan and Pathways, was also cited as one the nine defendants in a case of U.S. v. Janet Guerrero. The defendants included a medical director, Dr. Jose Calub, Ronald Malalis, who enrolled beneficiaries in Josdan and Pathways; Sharon Gulla, director of nursing of Josdan and quality assurance supervisor of Pathways; Mary Pilar Mendoza, who enrolled beneficiaries in Pathways; Isabelita Sabehon, who enrolled beneficiaries in Josdan and Pathways; Marilou Lozano, of Josdan and Pathways, all registered nurses of Cook County, Illinois; Sherwin Cubelo, of Lake County, Indiana, president of All in One Marketing, who recruited Medicare beneficiaries for Donnarich, Josdan and Pathways; and Janet Guerrero, of Cook County, manager of Josdan and owner of Pathways.

Court records showed that from January 2008 to March 2014, the defendants executed a scheme to defraud a healthcare benefit program “by means of materially false and fraudulent pretenses, representations and promises and property, owned by, and under the custody and control, of said healthcare benefit program, in connection with the delivery of and payment for health care benefits, items, and services thru conspiracy.”

Although a physician has certified that the beneficiaries were not homebound and were not qualified for home healthcare and did not need it, the defendants caused other physicians, including Jose Calub, to certify that the beneficiaries are eligible to receive home healthcare.

The defendants were able to submit claims for Medicare services that were not necessary and caused Medicare to make more than $60 million in payments for home healthcare services with at least $45 million of which were fraudulent.

They transferred and disbursed and caused the transfer and disbursement of funds from the various bank accounts of Donnarich, Josdan and Pathways and from secondary bank accounts that were funded by Donnarich, Josdan and Pathways to themselves and others.

The 243 defendants are charged with various healthcare fraud-related crimes, including conspiracy to commit healthcare fraud, violations of the anti-kickback statutes, money laundering and aggravated identity theft.

The charges are based on a variety of allegedly frauduleny schemes involving various medical treatments and services, including home healthcare, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and pharmacy fraud.

More than 44 of the defendants arrested are charged with fraud related to the Medicare prescription drug benefit program known as Part D, which is the fastest-growing component of the Medicare program.

“This action represents the largest criminal healthcare fraud takedown in the history of the Department of Justice, and it adds to an already remarkable record of enforcement,” said Attorney General Lynch.

“The defendants charged include doctors, patient recruiters, home healthcare providers, pharmacy owners, and others.  They billed for equipment that wasn’t provided, for care that wasn’t needed, and for services that weren’t rendered.  In the days ahead, the Department of Justice will continue our focus on preventing wrongdoing and prosecuting those whose criminal activity drives up medical costs and jeopardizes a system that our citizens trust with their lives.

“We are prepared – and I am personally determined – to continue working with our federal, state, and local partners to bring about the vital progress that all Americans deserve.”

“This Administration is committed to fighting fraud and protecting taxpayer dollars in Medicare and Medicaid,” said Secretary Burwell.  “This takedown adds to the hundreds of millions we have saved through fraud prevention since the Affordable Care Act was passed.  With increased resources that have allowed the Strike Force to expand and new tools, like enhanced screening and enrollment requirements, tough new rules and sentences for criminals, and advanced predictive modeling technology, we have managed to better find and fight fraud as well as stop it before it starts.”

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Joseph is a former reporter of the Manila Bulletin, former president of the Rizal-Metro Manila Reporters Association and former president of the Chicago chapter of the National Press Club of the Philippines. A native of Sorsogon, Philippines, he and his family now live in Chicago. A prolific reporter, Lariosa writes a column and news stories for the Filipino Star News and other Filipino community newspapers in the US as well as for GMA News and the Manila Bulletin.

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