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Court rejects Medicare fraud appeals

“Upon thorough review and with the benefit of oral argument, we affirm on all issues,” the U.S. Court of Appeals for the Eleventh Circuit said as it shot down the hopes of a doctor and three therapists. The four had appealed their convictions on conspiracy to commit health care fraud.

The court rejected their claim that their Florida trial had been unfair, as it upheld prison sentences and restitution ordered for “an extensive Medicare fraud scheme” that lasted seven years.

Prosecutors had argued that the scheme was orchestrated by the owner of Miami’s Health Care Solutions Network Inc. and several of its employees, including its medical director.

The company provided “partial hospitalization” for intensive psychiatric therapy for patients with serious mental disorders. However, Health Care Solutions violated Medicare’s documentation requirements by organizing “its business around procuring, retaining, and readmitting patients to maximize billing potential, without respect to patients’ health needs,” the appeals court said in its decision.

Patients were often recruited from assisted living facilities. If they didn’t qualify for the treatments, employees would falsify records and profiles to make it appear that they qualified. The patients were then “treated,” discharged and “recycled” (readmitted for more treatment).

Therapists fabricated notes about patients and copied and pasted from one patient’s file to others. The fraud also included billing for nonexistent patients and for services that were never rendered, the appeals court said.

The doctor now faces 16 years in federal prison and $23 million in restitution. The therapists each received 5 to 6 six years in prison and were ordered to pay $16 million each in restitution.

Their sentences should dispel any doubts that health care convictions are dealt with harshly. Investigation should be addressed seriously and immediately with the help of an experienced health care law attorney.