FBI Priorities Counterterrorism Foreign Counterintelligence Cyber AttacksHighTech Crimes

FBI Priorities • • • Counterterrorism Foreign Counterintelligence Cyber Attacks/High-Tech Crimes Public Corruption Civil Rights Criminal Enterprises White Collar Crime Violent Crime Support for Partners Technology

HEALTH CARE FRAUD SCHEMES • Services not Rendered • Upcoding • Unnecessary Services Simply to Bill • Kick Backs

HOME HEALTH CARE • CLINICS TYPES OF AMBULANCE SERVICES • PHARMACY MENTAL HEALTH FRAUD • HOSPITAL LABORATORY FRAUDS DME PHYSICIANS

Mental Health Facilities • • • Automatic Billing Charges for Patients Upcoding the Length of Visit Billing for Individual//Group Therapy • Kickbacks to Psychiatrist • Wave Therapy

NURSING HOMES • Kick Backs to Administrators • Cost Report Fraud (SNF) • Ancillary Providers • SNR // Upcoding • Therapists • Mobile X-Rays/EKGs • Labs • DMEs

Laboratory Frauds • • • Kickbacks to referring Dr. Unbundling // Bundling Sink Testing • SNR // Blood Donors

PHARMACEUTICAL FRAUD SCHEMES • • Billing for services not rendered Product substitution Package size fraud Miscoding of dosage Prescription shorting Substandard products Drug diversion

Analytical Products Internet Pharmacies • In 1999, $158 million worth of prescription drugs purchased online - $15 billion by 2004 • Estimated 200 to 400 web sites filling prescriptions without authorization • FDA estimates two million packages containing drugs enter the US through international mail yearly • Offshore pharmacies sell millions of dollars of unapproved prescription drugs to US citizens yearly-half of the web sites targeted by the FDA are located outside the US • Most of the FBI Internet Pharmaceutical-related cases are on the East Coast and Midwest.

Physician Frauds • • • Billing for Services Not Rendered Kickbacks for Referrals Upcoding • Billing for medically unnecessary procedures

DME FRAUD SCHEMES • Fake companies • False billing (SNR, SNMN, nonreimbursable vs reimbursable) • Kickbacks for referrals • Routine waiver of co-payment • Enteral nutrition fraud • Upcoding – New vs. used – Leased vs. purchased – Scooter vs. motorized wheelchair

CLINICAL FRAUD SCHEMES • • • Billing for services not rendered Upcoding Billing for medically unnecessary services Paying runners for patient referrals Kickbacks to Attorneys for referrals Kickbacks from laboratories/DMEs

HOSPITAL FRAUD SCHEMES • • • Billing for services not rendered Billing for uncovered services/items Submitting false claims Upcoding DRGs Misrepresenting patient diagnosis Kickbacks for patient admissions and referrals Premature discharge of patients Forging/altering patient records Cost report fraud Billing for a less qualified person

HOME HEALTH CARE FRAUD SCHEMES • • Billing for services not rendered Billing for medically unnecessary services Kickbacks to physicians to sign “Plans of Care” Forging physician signatures in order to bill Medicare Billing for non-reimbursable services Billing for unqualified patients Fabricating/altering visit notes Billing for housekeeping as if it were home health care • Billing unskilled services as skilled services

HOSPICE FRAUD SCHEMES • Billing for ineligible individuals • Billing for services not rendered • Kickbacks for patient referrals

AMBULANCE FRAUD SCHEMES • Wrong vehicle (i. e. transporting in a wheelchair van) • Padding mileage • Fraudulent destination codes • Waiving co-payment • False statements of medical necessity • Upcoding (billing for ALS when BLS was provided) • Billing for services not rendered • Kickbacks for patient referrals • Billing roundtrip vs. one-way

QUI TAMS • Private parties file civil actions to enforce the false claims act • Lawsuit is on behalf of citizen (relator) and U. S. Government joins • May result in a Criminal Investigation • Relator shares the settlement; up to 25%

Ari Kirschenbaum, dba SAMARITAN CARE, INC. • Kirschenbaum within a 28 month period received $11. 5 million for allegedly providing hospice services to nursing home residents • On 9/23/99, Kirschenbaum pled guilty to 3 year prison term • Kirschenbaum agreed to pay $22 million to Medicare, Medicaid, and private payers. • Kirschenbaum is permanently excluded from Medicare.

ABBOTT AMBULANCE • Terrence Dougherty, former President of Abbott • 4 week trial • Convicted of Mail Fraud and HCF on 7 -27 -00 • Billing for trips to Hospitals when they went to doctors office buildings • 1 year jail sentence; $250, 000 Criminal Fine • $325, 000 Civil Settlement • ABBOTT AMBULANCE • $5. 4 Million Civil Settlement on 8 -18 -00

SPECIALIZED HEALTHCARE PRODUCTS • $1, 500, 000 in payments for “incontinence kits” • 6 individuals prosecuted • 2 Nursing Home owners • 2 DME Operators • $2. 4 Million in Civil Settlements

South County Rehab • Edward C. Fann • Plead guilty to falsifying and inflating therapy hours on 4 -20 -00 • 1 year jail sentence; $619, 980 in Restitution • $525, 000 Civil Settlement • Gary Sanazaro Estate • $2. 8 Million Civil Settlement in July 2003

GENERAL AMERICAN • $76 Million Civil Settlement on 7 -26 -02 – Provided false information to CMS – Failed to process claims properly – Deleted QA claims selected for review • Carl Messina GA Medicare Director • Mary Wimbley, GA QA Manager – Plead Guilty on 10 -2 -02 – Conspiracy to falsify and hide from federal auditors information about payment errors

Robert D. Wachter dba AHM, Inc. • • $1. 25 Million Civil Settlement in 2005 18 month plea agreement in 2006 Charles Kaiser pleads guilty in 2007 Claywest, Oak Forest North, Lutheran Care Center – Understaffing, inadequate care – Dehydration, malnutrition

Sharon Otey Brenda Bassett • January 18, 2007, Otey sentenced to 44 months in prison and ordered to pay $313, 196 in restitution for posing as a Registered Nurse, stealing from patients in their homes • June 30, 2007, Bassett (a Bi-State bus driver) sentenced to probation for posing as a Licensed Practical Nurse

Dr. Krishnarao Rednam • April 11, 2008, Rednam sentenced to 10 months in jail, 2 years probation, $30, 000 fine and had his medical license suspended after he pled guilty to Obstruction of Justice for destroying records during a federal investigation. • Rednam agreed to pay $304, 225 to the U. S. • SLEC agreed to pay $251, 551 to the U. S. • Investigation revealed that Rednam purchased and administered an inexpensive drug Avastin , but billed for an expensive drug Macugen. • Rednam also purchased single use vials of Lucentis, but provided the Lucentis to multiple patients.

Jackie Hayes, dba Complete Care • • • Jackie Hayes, 48 months Gwen Silvers, 51 months Chante Hayes, 51 months Sharon Johnson and Earlean Hopson, probation Chante Hayes and Gwen Silvers convicted after 7 day trial on 2/5/08. • $2. 75 million paid by Missouri Medicaid for SNR, services provided to family members etc.

DILUTED TRUST ROBERT COURTNEY • Initiated in July 2001 in coordination with the FDA-OCI and USAO (Western District of Missouri) with the cooperation of Dr. Verda Hunter, an oncologist • Suspected that the amount of chemotherapy drugs dispensed to Dr. Hunter was significantly more than was purchased by the pharmacist who prepared them, Robert Courtney.