Riverside psychiatrist pleads not guilty in Medicare scheme

Report from the Houston Chronicle

A Houston psychiatrist who was indicted separately in the Riverside General Hospital $160 million Medicare billing fraud scheme pleaded not guilty on Friday and intends to stand trial in August.

Dr. Sharon Iglehart is accused of one federal conspiracy count, two health care fraud charges and a pair of allegations that she made false statements to investigators. At a pretrial conference before U.S. District Judge Ewing Werlein, her lawyers - which include high-powered defense attorney Rusty Hardin - said she is ready to face a jury. Iglehart originally was arrested in December 2013, but the allegations have been amended twice since then - growing from nine to 12 pages in the most recent indictment secured from a federal grand jury and filed on July 21. Iglehart pleaded not guilty to the amended five counts and retained her freedom on $50,000 bail.

Former Riverside CEO and president Earnest Gibson III was convicted as the ringleader in three conspiracies involving Medicare billings for Riverside's psychiatric treatment programs from 2005 to 2012 in which patients were ineligible for treatment or were warehoused but did not receive the reported care. The government alleged that $31 million in fraudulent reimbursement requests were paid. His son, former group home owner Earnest Gibson IV was also convicted at trial and sentenced to 20 years.

The elder Gibson received the heaviest punishment so far: 45 years. His second-in-command, Mohammad Khan, received a 40-year sentence. They received some of the nation's longest sentences for health care fraud - particularly, stealing from the Medicare or Medicaid programs, which is one of the top criminal prosecutorial priorities for the U.S. Justice Department.

Through her Iglehart Wellness Center, the psychiatrist allegedly participated in the scheme by submitting claims that falsely indicated she provided intensive outpatient services for severe mental illness through Riverside's treatment program. Iglehart retains an active medical license in Texas. She was reprimanded by the Texas Medical Board in 2009 for "recreating medical records for psychiatric patients significantly later than the time she had provided examination, diagnosis and treatment to the patients," according to the agency's website. Her disciplinary status was cleared in 2011.

Jury selection in Iglehart's case is set for Aug. 31. If convicted, the doctor faces up to 10 years in prison on each count. Regina Askew, who rose from a case worker to become an auditor, will spend 12 years in prison.

In July, Sharonda Holmes, who was involved in paying and receiving kickbacks, was sentenced to 3½ years and Waddie McDuffie became the sixth person to receive prison time in the scam that crippled Riverside. The historic Third Ward institution began as Houston's first hospital for black patients and became one of the state's largest providers of substance abuse and mental health treatment. McDuffie pleaded guilty to delivering kickback money to group home owners in exchange for them sending patients for mental health treatment at the hospital. He received a five-year term of probation and six months of home confinement. Those who have pleaded guilty or were convicted at trial are among the dozen defendants who are jointly responsible for $46 million in restitution.

All of the Riverside cases are being prosecuted by Washington-based lawyers assigned to the Justice Department's criminal fraud division.

Timberlawn mental hospital cut off from federal funding over safety issues

From a much long report in the Dallas News

Federal regulators are taking the rare step of kicking one of North Texas’ largest psychiatric hospitals out of the Medicare and Medicaid programs for leaving patients in “immediate jeopardy” of injury or death.

[...]

Timberlawn flunked a make-or-break inspection, a final chance to prove it could fix an array of problems after promising improvements for months.

The U.S. Centers for Medicare & Medicaid Services found that unlicensed personnel were monitoring patients and some patients were going more than 12 hours without seeing a nurse. Electrical cords and other unsafe objects remained in rooms within reach of suicidal patients.

“These practices posed an immediate jeopardy to the health and safety of patients,” inspectors said in a report.

The state said it is moving quickly to evaluate its enforcement options.

“The issues have been egregious and incredibly disheartening. We are absolutely looking at the full range of penalties, including license revocation,” said Carrie Williams, a spokeswoman for the Texas Department of State Health Services. “Our inspectors have been in and out of the facility since February, citing issues and not seeing progress. It’s turned into a critical situation.”

Much more information at the link, which includes hand wringing over what they will do when a dangerous and unsafe facility is shut down.

Poor treatment at Lehigh Valley mental health clinics was evident, patients say

From a longer report in the Lehigh Valley Live website

Photo caption:Lehigh Valley Community Mental Health Centers Inc. at 226 Northampton St., Easton, is seen July 20, 2015. It is one of 10 mental health clinics sued July 20, 2015, by the U.S. Attorney's Office for the Eastern District of Pennsylvania, along with owner Melissa Chlebowski and Melchor Martinez. Martinez is alleged to have run the Medicare- and Medicaid-funded clinics in Easton, Bethlehem, Allentown, Philadelphia and Raleigh, North Carolina, despite a 2000 ruling excluding him from participating in these and any federally funded health care programs.

Director Allison E. Frantz said the department received complaints about the delivery of care at Lehigh Valley Community Mental Health Centers Inc., now the target of a federal whistleblower lawsuit. The department forwarded the complaints, prompting an investigation, she said.

"The Northampton County DHS has taken steps to ensure the county's citizens' behavioral health treatment would not be jeopardized: the provider network was enhanced to include additional bi-cultural, bilingual treatment professionals and regular and frequent on-site clinical reviews, including additional billing audits," Frantz wrote in an email Tuesday.

After the U.S. Attorney's Office for the Eastern District of Pennsylvania announced the lawsuit Monday, patients were left with myriad questions about the care they had received and whether the five local centers in Easton, Bethlehem and Allentown would remain open.

The suit also targets the centers' owner, Melissa Chlebowski, and her husband, Melchor Martinez, both of Allentown, as well as four sister mental health centers in Philadelphia and one in North Carolina.

[...]

The suit alleges the mental health clinics used unqualified stand-ins for psychiatrists and rushed patients through "medication management" visits. Federal prosecutors also say the centers were really run by Martinez, despite being prohibited since 2000 from participating in Medicaid, Medicare or any federally funded health care programs.

The civil action seeks damages and penalties.

[...]

Owners of local mental health clinics face fraud charges

As Reported in the Philadelphia Business Journal

The U.S. Attorney’s Office for the Eastern District of Pennsylvania filed a civil health care fraud lawsuit Monday, under the False Claims Act, against an Allentown husband and wife and their network of mental health centers funded largely by Medicaid and Medicare.

The lawsuit names Melchor Martinez and Melissa Chlebowski, both of Allentown, as defendants and their businesses: Northeast Community Mental Health Centers in Philadelphia; Lehigh Valley Community Mental Health Centers in Allentown, Easton and Bethlehem; and North Carolina Community Mental Health Centers in Raleigh, N.C.

The complaint notes Martinez was convicted of Medicaid fraud in 2000 and, as a result, was excluded from participating in all federally funded health care programs including Medicaid and Medicare. The exclusion prohibited Martinez from owning, managing or receiving payments from any federally funded health care provider.

The lawsuit alleges that in spite of the exclusion, Martinez, assisted by his wife Chlebowski, continued to own and operate the Northeast and Lehigh Valley clinics, and that, in 2009, while his exclusion was ongoing, he started up the North Carolina clinic in Raleigh.

The complaint also says the clinics billed Medicaid for psychiatrist visits “of very brief duration, sometimes as little as two to three minutes, while fraudulently representing that patients were being seen for a 15 minute visit.”

The Northeast and Lehigh Valley clinics allegedly billed Medicaid and Medicare for the services of “therapists” who were not qualified to provide mental health services, and fraudulently billed Medicare for therapy services allegedly provided without the required supervision.

The complaint did not specify the damages being sought by the government.

The matter was investigated by the U.S. Department of Health and Human Services’ Office of Inspector General and the U.S. Attorney’s Office for the Eastern District of Pennsylvania, with assistance from the Pennsylvania Office of Attorney General and the North Carolina Department of Justice.

State of Conneticut Reaches False Claims Act Settlement with Providers at Children's Behavioral Health Clinic

From this Conneticut Attorney General Press Release.

A social worker and a doctor will pay a total of $120,000 to Connecticut's Medical Assistance Program (CMAP) through settlement agreements that resolve civil allegations involving the filing of false and fraudulent claims for payments at a Branford-based outpatient behavioral health clinic for children, Attorney General George Jepsen said today.

The state alleged that David M. Meyers, a licensed clinical social worker and former president of Cornerstones P.C., located in Branford, hired Dr. W. Blake Taggart to be the medical director of Cornerstones through an independent contractor agreement. Cornerstones' provider agreement with the state Department of Social Services (DSS) for participation in CMAP – which is the state's Medicaid program – required that the clinic comply with all applicable regulations. The state Department of Children and Families (DCF), which licenses and regulates outpatient psychiatric clinics for children, required Cornerstones to have a medical director. As part of Meyers' effort to maintain his clinic's enrollment in the CMAP beginning in January 2010, the DSS required an updated letter representing that Cornerstones continued to have a medical director overseeing care.

The state alleged that Dr. Taggart resigned as the clinic's medical director in September 2009, but two months later Meyers falsely stated in the letter to DSS that Dr. Taggart remained as the clinic's medical director. The state alleged that Dr. Taggart facilitated this misrepresentation by signing the false, back dated letter to DSS.

[...]

Houston Hospital Leaders Sentenced to 45 Years in Prison for Alarming Psychiatric Fraud Scheme

Details of the fraud allegations against Riverside General Hospital executives

The bulk of the Medicare and Medicaid fraud allegations against Gibson, et al. center around Riverside’s psychiatric facilities, which are classified by the government as a “partial hospitalization program” (PHP) A PHP is technically an outpatient treatment facility, but is geared toward the round-the-clock care required for patients enduring a severe mental illness. Under government guidelines, mental health patients receiving care at a PHP must be routinely seen by a psychiatrist, guided through a care plan, and carefully monitored throughout the course of treatment.

According to the allegations, Riverside collected more than $158 million in funds from Medicare and Medicaid on behalf of PHP patients who rarely, if ever, saw a psychiatrist for their illnesses. Moreover, Riverside regularly billed the government for psychiatric services that were never rendered, mostly because the patients were in the advanced stages of dementia and unable to participate in the treatment.

Patient care aside, Riverside is also accused of offering kickbacks and financial incentives to executives group homes, as well as recruiters tasked with increasing referrals of mental health patients to Riverside’s facilities.

In addition to the three main participants listed above, six other individuals recently pled guilty to conspiring with Gibson to bring in the maximum number of Medicare and Medicaid clientele.

According to a statement by the U.S. Attorney General’s Office, “The former President of Houston’s Riverside hospital, his son, and their co-conspirators saw mentally ill, elderly, and disabled Medicare beneficiaries as commodities to be turned into profit centers – not as vulnerable individuals in need of health care….Rather than providing needed medical care to a historically underserved community, the defendants ran a longstanding hospital into the ground through their greed and fraud. According to the evidence presented at trial, the defendants had patients sit around the facility watching movies while they received no treatment. Meanwhile, the defendants billed Medicare more than $158 million for care that was never provided. This brazen fraud cannot and will not be tolerated.”

See Also

Department of Justice Press Release, “Former President of Riverside General Hospital Sentenced to 45 Years in Prison in $158 Million Medicare Fraud.” June 9, 2015.

Fairfield psychiatrist charged with fraud. They submitted bills that added up to them seeing patients 24 hours a day.

The state attorney general is suing a Westport couple for Medicaid fraud, charging they submitted bills that added up to them seeing patients 24 hours a day.

Attorney General George Jepsen announced Thursday morning that Dr. Ashwini Sabnis, a psychiatrist, and her husband Saurav “Sam” Mohanty, co-owners of Brighter Concept, Inc., 2000 Post Road in Fairfield, allegedly filed false claims under the Connecticut Medical Assistance Program. The couple also operated a Brighter Concept office in New Haven.

Jepsen said he is seeking triple damages under the state’s False Claims Act for actions that occurred between January, 2010 and December of last year, including billing for services that garnered higher reimbursement levels than the services they actually provided. Jepsen alleged that the couple overbilled the state Department of Social Services by $768,171 during the four-year period.

The lawsuit, pursued by Jepsen and Department of Consumer Protection Commissioner Jonathan Harris, was filed in Hartford Superior Court.

"This action is being brought to seek damages, civil penalties and other relief due to a scheme that was perpetrated on a health care program intended to care for our most vulnerable citizens," Jepsen said in a statement. "Health care providers who accept taxpayer dollars must play by the rules."

The couple’s attorney, Ross Garber, declined comment.

The 42-page complaint alleges that the scheme included claims for services not rendered, as well as overbilling and filing false statements in a “systematic and persistent pattern of submitting false and fraudulent claims.” The lawsuit alleges that Sabnis and Mohanty discouraged auditors from the state Department of Social Services with claims that their computer system had crashed.

Sabnis regularly overbooked her scheduled Medicaid patients for 15 or 30 minute appointments, saw them for as little as 5 or 10 minutes, then used a reimbursement code that showed she spent as much as 75 to 80 minutes with them, the complaint said. The lawsuit alleges that there were 113 days when Sabnis billed the state for more than 24 hours of service for low-income and disabled patients.

Department of Social Services Commissioner Roderick L. Bremby praised the Attorney General’s investigation.

“Uprooting and eliminating this type of fraudulent activity requires the constant vigilance of oversight agencies,” Bremby said. “While the great majority of Medicaid-enrolled providers are professional and honest, the exceptions require aggressive action on behalf of the program’s overall integrity and the taxpayers who fund it.”

N.J. medical bribe scheme reached grand scale

Selections from the extensive report on NewJersey.com

The first hint of the vast bribery scheme came with the arrests of a North Jersey doctor and three businessmen who, authorities said, found a way to turn a diagnostic lab with offices in Parsippany and Garfield into a virtual gold mine.

Two years later, federal prosecutors in Newark have racked up convictions of 38 people, including 25 doctors from New Jersey, New York and Connecticut, in what is believed to be one of the largest — if not the largest — laboratory bribery prosecutions in the United States, both in terms of money and the number of physicians caught with their hands out.

“To our knowledge, this is the largest number of medical professionals ever prosecuted in the same case,” U.S. Attorney Paul J. Fishman said last week.

“It shows how pervasive this practice can be. It has also made people in the profession sit up and take notice and made the deterrent message that much louder,” he said.

In recent weeks two doctors, one weeping and both remorseful, have been sentenced after helping prosecutors catch others in cases that add to the broadening panorama of corruption.

By the numbers

• 25 doctors and one physician’s assistant pleaded guilty to accepting bribes.
• 16 of the doctors live in New Jersey; seven in New York; and two in Connecticut. The physician’s assistant is also from New Jersey.
• 12 other defendants who worked at Biodiagnostic Laboratory Services have pleaded guilty.
• The amount of bribes pocketed by individual doctors ranged from $10,500 to $1.8 million.
• In return for bribes, the doctors referred over $100 million in blood tests to the lab.
• So far, 12 doctors have been sentenced to terms ranging from one year of probation, for a cooperator, to more than three years in federal prison and fines of up to $75,000.

The government is seeking a combined forfeiture of more than $87 million from the 38 defendants, including $50 million from former BLS owner and president David Nicoll and $25 million from his brother, Scott Nicoll.

And it’s not over. Additional arrests of doctors who profited from the scheme are anticipated, prosecutors say.

Here is the section we are interested in from this extensive report on this large and complex scheme

A psychiatrist from Fort Lee, who practiced in Paterson, and a doctor from Ramsey are among 12 physicians who have already been sentenced. The psychiatrist, Claudio Dicovsky, admitted accepting $220,000 from BLS, but put a halt to the payments long before the feds came knocking. In January, he was placed on probation for three years, including one year of house arrest with electronic monitoring, and ordered to perform 1,500 hours of community service.

16 separate hospitals and their respective corporate parents have agreed to collectively pay $15.69 million related to fraudulent billing of psych services

Press Release From the US Department of Justice

Sixteen Hospitals to Pay $15.69 Million to Resolve False Claims Act Allegations Involving Medically Unnecessary Psychotherapy Services

The Justice Department announced today that 16 separate hospitals and their respective corporate parents have agreed to collectively pay $15.69 million to resolve False Claims Act allegations that the providers sought and received reimbursement from Medicare for services that were not medically reasonable or necessary, the U.S. Department of Justice announced today. 

“Hospitals that participate in the Medicare program must ensure that the services they provide and bill for are based on the medical needs of patients rather than the desire to maximize profits,” said Principal Deputy Assistant Attorney General Benjamin C. Mizer of the Justice Department’s Civil Division.  “The Department of Justice is committed to ensuring that those who seek to abuse the Medicare program will be held accountable for their actions.”

This case concerns claims to Medicare for Intensive Outpatient Psychotherapy (IOP) services.  IOP services represent a continuation of ambulatory psychiatric services and provide active treatment to individuals with mental disorders using a variety of treatment methods.  Medicare will pay for an appropriate course of IOP treatment provided a number of specific requirements are met including, most notably, that the services in question are reasonable and necessary for the diagnosis and treatment of the patient’s condition.

These settlements resolve allegations that, beginning as early as 2005 and in some cases continuing into 2013, the hospitals knowingly submitted claims for IOP services that did not qualify for Medicare reimbursement because: the patient’s condition did not qualify for IOP; the patient’s treatments were not provided pursuant to an individualized treatment plan designed to help the patient address specific mental health needs and reach achievable goals; the patient’s progress was not being adequately tracked or documented; the patient received an inappropriate level of treatment; and/or the therapy provided was primarily recreational or diversional in nature, and not therapeutic.  The IOP services in question were typically performed on the providers’ behalf by Allegiance Health Management (Allegiance), a post-acute healthcare management company based in Shreveport, Louisiana, but billed to Medicare by the providers.

The providers who have reached agreements to resolve these allegations with the United States include:

• Health Management Associates Inc. (HMA), and the following 14 hospitals formerly owned and operated by HMA: Central Mississippi Medical Center in Mississippi, Crossgate River Oaks in Mississippi, Dallas Regional Medical Center in Texas, Davis Regional Medical Center in North Carolina, East Georgia Regional Medical Center in Georgia, Gilmore Regional Medical Center in Mississippi, Lake Norman Regional Medical Center in North Carolina, Lehigh Regional Medical Center in Florida, Medical Center of Southeastern Oklahoma in Oklahoma, Natchez Community Hospital in Mississippi, Northwest Mississippi Regional Medical Center in Mississippi, Santa Rosa Medical Center in Florida, Southwest Regional Medical Center in Arkansas, and Summit Medical Center in Arkansas, which agreed to collectively pay $15 million;

• Community Health Systems and its subsidiary Wesley Medical Center in Mississippi, which agreed to pay $210,000; and

• North Texas Medical Center in Texas, which agreed to pay $480,000.

In October 2013, the United States resolved similar allegations with LifePoint Hospitals Inc. and two of its subsidiaries, PHC-Minden L.P., doing business as Minden Medical Center, and PHC-Cleveland Inc., doing business as Bolivar Medical Center, which collectively paid $4,672,469.80.

“This case demonstrates that the U.S. Attorney’s Office for the Eastern District of Arkansas will aggressively pursue civil health care fraud cases, where the integrity of the Medicare system has been undermined,” said U.S. Attorney Christopher R. Thyer of the Eastern District of Arkansas.  “Medical care providers who abuse Medicare hurt all taxpayers, and today’s announcement highlights our commitment to protecting our national health care system, as well as the Arkansans who depend on it.”

“Our agency is dedicated to investigating health care fraud schemes such as this, which divert scarce taxpayer funds meant to provide for legitimate patient care, including services for the often underserved mentally ill population,” said Special Agent in Charge Mike Fields of U.S. Department of Health and Human Services-Office of Inspector General (HHS-OIG).

The allegations resolved by today’s settlements arose from a lawsuit filed under the False Claims Act.  The act allows private individuals known as “relators” to sue on behalf of the United States and to share in the proceeds of any settlement or judgment that may result.  The relator in this case will receive $2,667,300. 

These settlements were the result of a coordinated effort by the Civil Division’s Commercial Litigation Branch, the U.S. Attorney’s Office for the Eastern District of Arkansas and HHS’ Office of Audit Statistics and OIG.

These settlements illustrate the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services.  The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.  One of the most powerful tools in this effort is the False Claims Act.  Since January 2009, the Justice Department has recovered a total of more than $24 billion through False Claims Act cases, with more than $15.3 billion of that amount recovered in cases involving fraud against federal health care programs.

The claims settled by these agreements are allegations only, and there has been no determination of liability. 

Physician Sentenced for $5.5 million Medicare fraud scheme involving fraudulent billings by a psychiatric hospital

As seen in this report

A Miami-area medical doctor was sentenced recently to 60 months in prison for his role in a $5.5 million Medicare fraud scheme involving fraudulent billings by a psychiatric hospital in Hollywood, Florida.

Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida, Special Agent in Charge George L. Piro of the FBI’s Miami Field Office and Special Agent in Charge Shimon Richmond of the U.S. Department of Health and Human Services Office of Inspector General’s (HHS-OIG) Miami Regional Office made the announcement.

Barry Kaplowitz, 54, of Aventura, Florida, a licensed physician, was convicted of making false statements related to health care matters on Feb. 20, 2015, following a six-week jury trial. In addition to the recent prison sentence, U.S. District Judge Cecilia M. Altonaga of the Southern District of Florida ordered Kaplowitz to pay more than $2.9 million in restitution.

According to evidence presented at trial, Kaplowitz served as the medical director at Hollywood Pavilion (HP), a state-licensed psychiatric hospital, from approximately 2008 to 2011. During that time, Kaplowitz signed false and fraudulent medical records in order to make it appear that HP’s patients qualified for and received intensive outpatient services, even though they did not. The evidence demonstrated that Kaplowitz signed patient files for over 400 patients certifying that he had provided mental health services to each of them, even though he never saw nor provided any treatment to the patients. HP used these falsified medical records to submit over 2,800 false claims to Medicare totaling over $5.5 million. Medicare paid $2.9 million on those false claims.

Five other individuals have previously been convicted and sentenced in this case:

• Karen Kallen-Zury, of Lighthouse Point, Florida, HP’s former chief executive officer, was sentenced to 25 years in prison;
• Daisy Miller, of Hollywood, the clinical director of HP’s inpatient facility, was sentenced to 15 years in prison;
• Michele Petrie, of Fort Lauderdale, Florida, the head of HP’s intensive outpatient program, was sentenced to six years in prison;
• Christian Coloma, of Miami Beach, Florida, the director of physical therapy for an entity associated with HP, was sentenced to 12 years in prison; and
• Christopher Gabel, of Davie, Florida, HP’s former chief operating officer, was sentenced to six years in prison.

GAO Finds Major Overuse of Antipsychotic Drugs by the Elderly

From the Illinois Nursing Home Abuse Blog

In late 2014 we blogged about the accusations levied against Dr. Michael J. Reinstein about his improper use of antipsychotic drugs prescribed to patients in abundance, as well as taking kickbacks from the drug maker to prescribe it, and making 140,000 or more false billing claims submitted to Medicare and Medicaid for those treatments. This activity landed him in both civil and criminal hot water, and in more recent news he pled guilty to criminal charges as well as settled civil claims with the Illinois and federal governments.

The companies accused of providing those kickbacks and receiving Medicare and Medicaid dollars from the business Reinstein generated by prescribing their antipsychotic drugs. Reinstein exemplifies a holdover of a slowly diminishing practice of using antipsychotic medications, which now is viewed more as the easy way out and a method of chemical restraint when there are other methods that could more humanely calm and care for a patient, particularly dementia and Alzheimer’s patients who have historically been the recipients of antipsychotic medications. Nursing homes historically used these especially when they kept low staffing levels and did not have the manpower to aid patients. Yet antipsychotic drugs can create a cycle of drug dependency, and can even lead to death.

Changing Tides?

While the movement to eliminate the use of antipsychotic medications has gained steam in recent years, the federal government reports that elderly Americans have been overusing psychiatric drugs such as clozapine (Dr. Reinstein’s apparent drug of choice), Abilify, and others. Such drugs are meant to calm down and sedate patients that are prone to violence or outbursts, which those suffering from dementia or psychosis may be particularly prone to exhibiting. The Government Accountability Office (GAO) has released a report stating that elderly adults who live outside of nursing homes and long-term care facilities overuse antipsychotic drugs which are prescribed to them by doctors, though residents in nursing homes also fell into such dependency and overuse, and efforts to curb over-prescription and overuse must continue there as well.

Notably, according to the report, about 86% of Medicare enrollees who suffer from dementia and live outside of nursing homes are prescribed antipsychotic medications, which is a staggering statistic. It is even more remarkable when considering that only approximately 6% of total Medicare enrollees living outside of nursing homes suffer from dementia. Thus the choice of treatment has predominantly been geared toward chemical intervention. For those in nursing homes, of the elderly dementia patients living in nursing homes for over 100 days in the year 2012, approximately a third of those patients were prescribed antipsychotic drugs (and 14% of those outside of nursing homes during 2012).

Part of the problem, according to the GAO report, is the lack of oversight by the government. Medicare and Medicaid specifically take responsibility for such oversight on behalf of the federal government, and states typically have Medicaid fraud units that look into not only financial fraud related to health care, but also investigate when issues include abuse or misuse of medications (which can result in unnecessary and excessive, and thus fraudulent, payments to providers and pharmaceuticals with federal dollars). Those agencies and offices, as well as the U.S. Department of Health and Human Services as the report notes, should be vital in promoting awareness of the dangers of antipsychotic drugs and reducing that use far more than the government has in the past.

Psychiatrist Settles Pleads Guilty and Settles Civil Claims

As seen on the Illinois Nursing Home Abuse Blog

Background

A few months ago, an Illinois psychiatrist was suspended indefinitely from practicing because of his alleged abuse of an antipsychotic drug called clozapine. Dr. Michael J. Reinstein prescribed clozapine to more than half of his patients at nursing homes as well as mental health facilities. Clozapine is used to keep patients sedated when they become irritable or violent – many of them suffer from dementia or other ailments, and antipsychotic drugs such as clozapine are used to hold them down. Such drugs can be considered an unacceptable form of chemical restraint that advocates have fought against in recent years in favor of more humane methods that avoid drug dependency.

Constant drug use by patients as prescribed can put them in a stupor and can hasten their mental and/or physical demise. Clozapine adversely affects the immune system by diminishing white blood cells, and can cause heart inflammation, seizures, and problems with the blood, as well as dizziness and lightheadedness. As we profiled earlier in this space, clozapine itself is one of the most dangerous types of antipsychotic medications, and is considered “a risky drug of last resort.” Historically, Dr. Reinstein was alleged to have prescribed more clozapine in a single year (2007) than all medical providers in the large state of Texas combined, and has had patients die in the past while on substantial doses of clozapine.

Charges, Guilty Plea and Settlement

Reinstein was also accused of taking about $350,000 in kickbacks, including gifts (like travel and dinners) from a clozapine manufacturer, Teva Pharmaceuticals, which is against the law. Teva already settled with the government over those kickback allegations. The government also sued Reinstein for taking kickbacks to prescribe clozapine, and for submitting possibly more than 140,000 false claims (overbilling) for reimbursement for these treatments from the federally funded programs Medicare and Medicaid. This type of Medicare/Medicaid fraud is prosecuted civilly and criminally under the False Claims Act, and such allegations are very serious. In recent news, Reinstein, already dealing with a suspended license and a civil suit from the government for taking kickbacks and committing medication fraud, has been charged criminally by the United States for taking kickbacks from the clozapine drug maker.

As reported by the Chicago Tribune, the criminal charges have been brought on a single kickback worth $2,000, but the government was reportedly looking to take back approximately $600,000 worth of “ill-gotten gains stemming from clozapine prescriptions.” Just days ago, Reinstein pled guilty to the federal charge of accepting kickbacks for prescribing clozapine against the Medicare and Medicaid Anti-Kickback Statute. His sentencing date is as yet unscheduled, but the please agreement includes a recommendation of 18.5 months behind bars. Along with the guilty plea, Reisnstein settled the civil case with both the Justice Department and the State of Illinois (which later joined the federal government in that suit) for $3.79 million, settling claims that he accepted kickbacks to prescribe clozapine and then submitted an astounding amount of false claims for reimbursement.

Takeaway

This case demonstrates the importance of cracking down on Medicare and Medicaid fraud, as well as companies and medical providers engaging in kickback schemes. This is an illegal way to “get rich” at the expense of patients who are not prescribed what they need or do not receive the appropriate treatment because doctors are prescribing medications as part of the kickback scheme. This case also highlights the abuse of federal taxpayer dollars through reimbursement claims. And above all, it puts the spotlight on the abuse of medications for chemical restraints, and how we must continue moving toward alternative methods.

Jurors to decide fate of South Florida psychiatrist, others in Medicare fraud trial

Highlights from an extended report in the Miami Herald

Barry Kaplowitz was a psychiatrist with a “robotic” signature who signed off on thousands of bogus treatments at a Hollywood psychiatric facility that bilked Medicare for millions — even when he was out of the country, prosecutors say.

“It’s not just any kind of signing; it’s robo-signing,” Justice Department prosecutor Andrew Warren declared during closing arguments at his Miami federal trial.

[...]

On Tuesday, Miami federal jurors resumed deliberating the fate of Kaplowitz, 54, an Aventura psychiatrist who worked part-time as the medical director of Hollywood Pavilion’s outpatient facility, and two other defendants on charges of conspiring to defraud Medicare and related offenses.

[...]

The other defendants are Melvin Hunter, 63, a Broward resident who worked as an admissions supervisor for Hollywood Pavilion’s inpatient facility, and Tiffany Foster, 49, an Alabama resident accused of taking bribes to refer mental health patients.

A fourth defendant, Christopher Gabel, 62, of Davie, the former chief operating officer, pleaded guilty in November to conspiring to commit healthcare fraud and pay kickbacks to patient recruiters. Gabel, who is serving a six-year prison term, testified that Medicare beneficiaries — including drug addicts with disability status — were admitted regardless of whether they qualified for treatment or even saw a doctor.

The latest trial followed the 2013 conviction of Hollywood Pavilion's chief executive officer, Karen Kallen-Zury, of Lighthouse Point, who was found guilty along with three other employees of conspiring to bilk $67 million from Medicare by filing phony claims for mental health services from 2003 to 2012. Medicare was tricked into paying $40 million to Hollywood Pavilion. Of those defendants, Kallen-Zury received the longest sentence: 25 years.

During the six-week trial, prosecutors presented evidence showing that Kaplowitz generated $6.5 million in false claims for Medicare patients who did not need psychiatric treatment, resulting in $3 million in tainted income for Hollywood Pavilion between 2008 and 2011. The psychiatrist was paid $1,250 a month over that period for showing up one day a week to sign charts and other paperwork to justify 2,800 false claims to Medicare, prosecutors said.

[...]

The prosecution of Kaplowitz, Hunter and Foster was the latest crackdown by the Justice Department and U.S. attorney's office against operators of mental-health facilities accused of fleecing the Medicare program.

Three previous major prosecutions led to the convictions of about 100 clinic operators, doctors, therapists and patient recruiters at American Therapeutic, Biscayne Milieu and Health Care Solutions Network in South Florida.

Several of those convicted defendants testified at the latest trial. Among them: Dr. Alan Gumer, a former medical director at the Hollywood Pavilion facility who is serving a 21/2-year sentence in the American Therapeutic case, and Keith Humes, a Hollywood Pavilion patient recruiter who is serving a seven-year prison sentence stemming from another Medicare fraud offense.

Chicago psychiatrist pleads guilty to taking drug kickbacks

As reported by ABC channel 7 in Chicago

A long-time Chicago psychiatrist pleaded guilty Friday to receiving illegal kickbacks and benefits totaling nearly $600,000 from pharmaceutical companies in exchange for prescribing an anti-psychotic drug to his patients.

Dr. Michael J. Reinstein, 71, of Skokie, has also agreed to pay $3.79 million to settle a civil lawsuit alleging that he caused the submission of at least 140,000 false Medicare and Medicaid claims for the thousands of patients he prescribed Clozapine to in nursing homes and other facilities in exchange for kickbacks.

"The defendant put his patients at great risk of serious health problems to benefit his personal interests at taxpayer expense," said Attorney General Lisa Madigan, whose office handled the civil litigation.

Reinstein's plea agreement calls for the government to recommend a sentence of 18.5 months in prison when he is sentenced.

Monroeville psychiatrist charged with billing Medicaid while license suspended

As reported by eTrib Live

A Monroeville psychiatrist accused of Medicaid fraud, theft and delivery of controlled substances had lost his license through Pennsylvania and Ohio suspensions.

The state attorney general's office on Thursday charged Jopindar P. Harika, 61, with more than 100 counts of Medicaid fraud, attempted Medicaid fraud, theft by deception, tampering with public records, delivery of a controlled substance and unlawful prescribing.

“I'm confident that once he has his day in court, we will be able to prevail in these charges,” said Jan Ira Medoff, Harika's attorney. “These are just allegations.”

Harika told a grand jury he was aware his license was suspended for 32 days in 2012 because of unpaid child support in Allegheny County when he is alleged to have seen 565 patients and written prescriptions for at least 453 patients at three mental health agencies in Philadelphia and Berks County.

According to the grand jury presentment, “Harika gave a variety of excuses as to why he continued to practice medicine when he knew that his license was suspended.”

Many of the clients that Harika reported seeing were not billed to Medicaid, but according to the presentment, Harika did bill $59,000 to Medicaid through three agencies: Multicultural Wellness Center in Philadelphia and Reading Behavioral Health Services and Child and Family Support Services in Reading.

The agencies paid him $73,380 in salary.

Administrators from the three facilities said they fired Harika at varying points in 2013.

Multicultural returned $135,000 in fraudulent billing based upon Harika's suspended medical license.

“A doctor's mission should be to provide the best treatment possible for patients, not exploit them to make money,” Attorney General Kathleen Kane said.

Harika is free on $25,000 bond.

According to a report from the State Medical Board of Ohio, Harika's problems began with a 1997 theft charge to which he pleaded guilty. The report stated that Harika billed Somerset State Hospital and Pennsylvania for medical services he did not provide. In 1999, he was sentenced to four years of probation, ordered to pay $84,609 in restitution to Pennsylvania and provide free treatment to mental health patients during the first two years or his probation.

Ohio suspended Harika's license to practice for at least two years; the Pennsylvania State Board of Medicine suspended his license for two months, fined him $700 and put him on probation.

The U.S. Attorney for the Northern District of Illinois filed a single felony charge against Dr. Michael Reinstein, a Chicago psychiatrist took kickbacks for prescribing an antipsychotic drug

As reported on ProPublica

Be sure to the original for many extar links related to the story

A former Chicago psychiatrist who was the nation's top prescriber of the most powerful and riskiest antipsychotic drug intends to plead guilty to a federal felony charge of taking kickbacks from its manufacturer in exchange for prescriptions, court records show.

The U.S. Attorney for the Northern District of Illinois filed a single felony charge against Dr. Michael Reinstein this week for taking $2,000 in November 2009 from drugmaker Teva "in return for Reinstein's referrals of patients" for clozapine prescriptions.

Clozapine, also known as Clozaril and FazaClo, is approved to treat schizophrenia patients who don't respond to other medications. But it can have dangerous side effects, including seizures, inflammation of the heart muscle, and a drop in white blood cells. The drug is considered particularly risky for elderly patients.

A note in court records says that Reinstein intends to plead guilty at his arraignment next Friday. The action was first reported by the Chicago Tribune.

Reinstein's prescribing patterns have been detailed in two ProPublica reports.

In 2009, ProPublica and the Chicago Tribune reported how in one year Reinstein prescribed more of the antipsychotic clozapine to patients in Medicaid's Illinois program than all doctors in the Medicaid programs of Texas, Florida and North Carolina combined. Autopsy and court records showed that at least three patients under Reinstein's care had died of clozapine intoxication. At that time, Reinstein defended his prescription record, arguing that clozapine is effective and underprescribed.

Then, in 2013, as part of a ProPublica investigation into Medicare's failure to monitor problem prescribers, we reported that Reinstein prescribed even more clozapine in Medicare's prescription drug program for seniors and the disabled. Medicare continued to let him prescribe in the program even after the U.S. Department of Justice accused him of fraud and Illinois' Medicaid program suspended payments to him.

The U.S. Attorney's office declined to discuss Reinstein's upcoming plea. Reinstein's attorney, Terence Campbell, did not immediately return a phone call from ProPublica seeking comment. He told the Tribune on Thursday that Reinstein was "working toward resolving the issues raised by the government and hopes to put this episode behind him soon."

The Tribune reached Reinstein, as well, yesterday. He would not discuss the criminal case but denied any payments from Teva, clozapine's manufacturer, were for prescribing the drug. The doctor instead said the money was for lectures he gave.

In November 2012, the federal government filed a civil fraud lawsuit against Reinstein, saying he "received illegal kickbacks from pharmaceutical companies and submitted at least 140,000 false claims to Medicare and Medicaid for antipsychotic medications he prescribed for thousands of mentally ill patients in area nursing homes."

Last August, Illinois medical regulators indefinitely suspended Reinstein's medical license after determining that Reinstein received " illegal direct and indirect remuneration" from the maker of generic clozapine, did not consider alternative treatments for his patients, and disregarded patients' well-being. In response to the medical board's accusations, Reinstein's lawyers invoked his right against self-incrimination.

Early last year, Teva Pharmaceutical Industries Ltd., the maker of generic clozapine, agreed to pay more than $27.6 million to settle state and federal allegations that it induced Reinstein to prescribe the drug.

Reinstein's prescribing of clozapine appears to have declined after our 2009 articles about him. From 2007 to 2009, he wrote an average of 20,000 Medicare prescriptions annually for clozapine and the brand-name version, FazaClo. That figure dropped to about 8,000 in 2012, according to data obtained by ProPublica.

Mount Carmel psychiatrist Andrew Newton pleads guilty to Medicare fraud

As reported on NewsItem.com

A Mount Carmel psychiatrist accused of fraudulently billing Medicare for psychotherapy sessions that didn't happen has pleaded guilty to the charges in federal court Nov. 25.

Dr. Andrew Newton, 42, of Harrisburg, the owner-operator of the Newton Psychiatric Clinic, pleaded guilty to six counts of theft or embezzlement in connection with health care in the Nov. 25 court appearance.

Following the plea, U.S. Magistrate Judge Martin C. Carlson ordered a presentence investigation to be completed by Dec. 23, but Newton's attorneys asked for a continuance, which was granted on Dec. 1. The report must be completed and published on or before Jan. 20, 2015.

Authorities alleged Newton billed Medicare for a face-to-face psychotherapy services with patients in Pennsylvania when Newton was out of the country.

The U.S. Government alleged Newton billed Medicare for three patients Aug. 18, 2010, and for patients Sept. 2 and Sept. 3, 2010, when the doctor was in France, and Nov. 29, 2011, when Newton was in England.

Newton "did knowingly and willfully embezzle, steal and convert to his own use" a total of $322.75 from the fraudulent billing, a past release stated.

A plea agreement reached said Newton will plead guilty to all six of the misdemeanor charges, and the government will not bring any other criminal charges related to the offenses, with the exception of criminal tax charges.

In this case, Newton faces a maximum sentence of six years in prison, a term of supervised release following the imprisonment and a fine.

The plea agreement also states that Newton agrees to make full restitution of $20,000, plus $75,000 payable to the Medicare Trust Fund.

The investigation was conducted by the U.S. Department of Health and Human Services, the Office of the Inspector General and the Federal Bureau of Investigation's Williamsport Office.

Mental Health Ranks High on Fraud Scale

A recent column by Richard Kusserow

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Kusserow’s Corner: Mental Health Ranks High on Fraud Scale

Occasionally, I take time to bring attention to enforcement actions in various health care sectors. Some recent actions drew my attention back to a special enforcement problem that stretches back decades to my days as Inspector General—mental health. Billions of dollars are spent to address the ever-increasing demand to treat mental stress and illness. The primary purpose of mental health treatment must be the therapeutic care and treatment of individuals who are suffering emotional disturbance. Proper treatment therefore demands the highest level of trustworthiness and integrity in the practitioner, who treats some of the most vulnerable patients. Two sources of funding are Medicaid and state general fund dollars, which on average fund 90 percent of the system. However, about 10 percent is funded by Medicare, federal mental health services block grant funds, and county or municipal funds. As with other areas of health care, a significant portion of these funds are diverted to fraud within the mental health industry. Many health care fraud investigators believe mental health caregivers, such as psychiatrists and psychologists, have the worst fraud record of all medical disciplines. Much of that is attributable to prescriptions for narcotic drugs and taking advantage of some of the vulnerable individuals who suffer from mental illness or Alzheimer’s disease.

Last year the HHS Office of Inspector General (OIG) issued a report focusing on one aspect of the problem: detecting and deferring mental health fraud in community mental health centers (CMHCs). CMHCs provide partial hospitalization program services to approximately 25,000 Medicare beneficiaries. The OIG report cited numerous arrests by Medicare Fraud Strike Forces evidencing significant levels of CMHC fraud. The OIG review found that one of nine MACs reviewed performed activities to detect and deter CMHC fraud, and most of these were part of a CMS-led special project. Activities to detect and deter CMHC fraud varied substantially among ZPICs with many performing minimal activities to detect and deter fraudulent CMHC billing. The report provided a number of recommendations to increase control and enforcement in this arena. However, this is only one area of Medicare that addresses mental health. Other areas are equally prone to fraud and abuse.

The latest in the Medicare enforcement arena comes from Louisiana where the owner of three mental health centers was sentenced to pay $43.5 million in restitution and serve 8-and-one-half years in federal prison for a Medicare fraud scheme. A psychiatrist, who served as medical director and co-owner, was sentenced to 86 months in prison for his role in admitting mentally ill patients to the facilities, some of whom were inappropriate for partial hospitalization, and then re-certifying the patients’ appropriateness for the program in an effort to continue to bill Medicare for services. These were among 17 people who worked at the three facilities in a variety of roles who also been charged in the fraudulent operation that stretched seven years and involved over a quarter-billion dollars in Medicare fraud. They included therapists, marketers, administrators, owners, and the medical director. The companies billed Medicare for unnecessary or never provided partial hospitalization program services for the mentally ill. The companies, collectively, submitted more than one-quarter-billion dollars in claims to Medicare during this period. The scheme also involved falsifying records indicating patients had treatment they never received and paying recruiters to, in turn, pay patients to attend hospitalization programs at the facility in order to make Medicare claims.

The fraud problem is actually larger and more pervasive in the Medicaid program, which provides significantly more funding to this area. For example, last year New Mexico was in the midst of a sweeping criminal investigation into 15 of its largest mental health providers, suspected of defrauding Medicaid of $36 million over three years.

Examples of Fraud in the Mental Health Sector

• Altering and/or falsifying records to match services billed
• Billing for services not actually performed
• Errors and falsification of patient charts
• Fabricating patient files
• Paying kickbacks paid to recruiters to find beneficiaries
• Lack of a referral form from an approved provider source
• Lack of documentation for service provided
• Service notes lack specific treatment goal
• Billing for service not covered by Medicaid as a covered service
• Billing for a more expensive service than was actually rendered
• Prescribing category narcotic drugs to addicts or for selling on the street
• Changing the billed date of service to match client dates of eligibility
• Deliberately applying for duplicate reimbursement in order to get paid twice
• Inappropriate billing that results in a loss to the Medicaid program
• Providing services which are not necessary
• Billing for services performed by unqualified persons

Mental health scams target Medicare and Medicaid

As seen in this report

Fraud involving Medicare and Medicaid mental health benefits has been "a special enforcement problem that stretches back decades," according to former Department of Health and Human Services Inspector General Richard P. Kusserow. "Many healthcare fraud investigators believe mental health caregivers, such as psychiatrists and psychologists, have the worst fraud record of all medical disciplines," Kusserow wrote. That belief is largely based on numbers of prescriptions for narcotics and exploitation of patients diagnosed with mental illness or Alzheimer's disease.

One fraud hotspot is community mental health centers (CMHCs) that offer partial psychiatric hospitalization programs. In Medicaid, there's been "an explosion of fraud in community-based treatments," including billing for services not rendered, services provided by unlicensed staff or services tainted by kickbacks, according to Assistant U.S. Attorney Ted Radway.

The Medicare Strike Force made arrests for significant CMHC fraud involving programs serving about 25,000 beneficiaries, Kusserow noted. Yet just one out of nine Medicare Audit Contractors reviewed last year by the Office of Inspector General worked to thwart CMHC fraud, Kusserow noted. This finding led the agency to recommend increased controls and enforcement in this area.

A recent case involved Louisiana psychiatrist Zahid Imran who was sent to prison for his role in a Medicare scam involving partial hospitalization services. Imran admitted patients who didn't need partial hospitalization and then recertified their appropriateness for the program to keep the Medicare reimbursement flowing. Imran's crimes were part of a $258 million fraud scheme in which 17 people were convicted, including therapists, marketers, administrators, and owners of facilities in two states. Perpetrators paid recruiters to round up patients and altered documentation to make it look like they received treatment.

Mental health fraud is more pervasive in Medicaid, Kusserow wrote, since Medicaid and the states provide more funding to this area than Medicare. Last year, for example, New Mexico investigated 15 of its largest mental healthcare providers who were suspected of cheating Medicaid out of $36 million in three years.

Anchorage psychiatrist changes his plea to guilty in Medicaid fraud case

As Reported on KTUU



(I have edited their report for purposes of clean up errors, typos, etc)

Anchorage psychiatrist Dr. Shubu Ghosh has changed his plea in a case of fraudulently billing Medicaid and tampering with evidence. Dr. Shubu Ghosh has plead guilty to billing Medicaid more than $1 million for services he never performed. He said he was guilty for falsifying records in an attempt to cover up the improper billing. Ghosh founded Gosh Psychiatric Services and was arrested in April of this year. His sentencing is set for April of next year, and he could spend one to three and a half years in jail and pay a fine of up to $50 thousand.