DOJ Catches Conspirator in Largest Ever Health Care Fraud Scheme

Jerry Ashworth
April 10, 2019 at 11:29:31 ET
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When you see a federal agency use the words “largest ever” in the headline, you know it must be big news. The U.S. Department of Justice (DOJ) recently reported that a federal jury found a South Florida health care facility owner guilty for his role in the largest health care fraud scheme ever charged by DOJ, involving more than $1.3 billion in fraudulent claims to Medicare and Medicaid for services that were not provided, were not medically necessary or were procured through the payment of kickbacks.

After an eight-week trial, Philip Esformes, 50, of Miami Beach, Fla., was convicted of one count of conspiracy to defraud the U.S., two counts of receipt of kickbacks in connection with a federal health care program, four counts of payment of kickbacks in connection with a federal health care program, one count of conspiracy to commit money laundering, nine counts of money laundering, two counts of conspiracy to commit federal program bribery, and one count of obstruction of justice before U.S. District Judge Robert N. Scola Jr. of the Southern District of Florida. Sentencing has not yet been scheduled.

“Philip Esformes’ criminal scheme defrauded America’s health care system out of millions of dollars, that would have otherwise provided quality care to patients in need,” said U.S. Attorney Fajardo Orshan. “I commend the Assistant U.S. Attorneys from the Southern District of Florida, who worked tirelessly alongside their partners at the DOJ’s criminal division, the [Federal Bureau of Investigation and the Department of Health and Human Services’ Office of Inspector General to bring this case to justice. This massive fraud scheme, perpetuated in nursing and assisted living facilities in our South Florida communities, compromised the integrity of our local health care system. We remain united in our commitment to root out health care fraud and support quality patient care.”

DOJ stated that according to evidence presented at trial, from approximately January 1998 through July 2016, Esformes led an extensive health care fraud conspiracy involving a network of assisted living facilities and skilled nursing facilities that he owned. Esformes bribed physicians to admit patients into his facilities, and then cycled the patients through his facilities, where they often failed to receive appropriate medical services, or received medically unnecessary services, which were then billed to Medicare and Medicaid, the evidence showed.

Several witnesses testified to the poor conditions in the facilities and the inadequate care patients received, which Esformes was able to conceal from authorities by bribing an employee of a Florida state regulator for advance notice of surprise inspections scheduled to take place at his facilities. The evidence further showed that Esformes used his criminal proceeds to make a series of extravagant purchases, including luxury automobiles and a $360,000 watch. Esformes also used criminal proceeds to bribe the basketball coach at the University of Pennsylvania in exchange for his assistance in gaining admission for his son into the university. Altogether, the evidence established that Esformes personally benefited from the fraud and received in excess of $37 million.

Glad to see this this man was caught. There is no place for fraud in Medicare or Medicaid.

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