Healthcare Fraud & Abuse Remains Top DOJ Criminal Enforcement Priority

Posted On Monday, March 18, 2013
By: James W. Kraus

In February, HHS and DOJ released their Annual Report for the Health Care Fraud and Abuse Control Program, describing yet another “record breaking year” in healthcare fraud and abuse enforcement.  While there are no formal reports to cite regarding activity in 2013, it certainly appears that the trend will continue.  Just a review of a few of the cases that made news at the end of last week is sufficient to make this point.

“During 2012, federal prosecutors had 2,032 health care fraud criminal investigations pending, involving 3,410 potential defendants, and filed criminal charges in 452 cases involving 892 defendants.”

On Friday, the former medical director of Biscayne Milieu, a Miami-based mental-health clinic, was sentenced to 144 months in prison for his role in a fraud scheme involving the submission of more than $50 million in fraudulent billings to Medicare.  Dr. Gary Kushner’s conviction came after a two month trial where the evidence showed that he and co-conspirators submitted over $50 million dollars in false and fraudulent claims to Medicare.  The claims were submitted through the Biscayne Milieu facility that purportedly operated a partial hospitalization program (PHP), a form of intensive treatment for severe mental illness.  Instead, patient recruiters were paid to refer ineligible Medicare beneficiaries to the facility for services that were never provided or were not properly reimbursable by Medicare. 

On Thursday, a Houston-area physician was sentenced to serve 63 months in prison for conspiring to commit health care fraud by falsifying plans of care for Medicare beneficiaries, including patients whom he did not treat.  Dr. Ben Harris Echols’ conviction came after a trial where the evidence showed that he signed plans of care for Medicare beneficiaries who were not under his care and about whose conditions he had no knowledge.  In addition to his prison term, the physician was sentenced to serve three years of supervised release and ordered to pay over $2 million in restitution.

On the same day of the sentencing of Dr. Echols, a Houston grand jury returned a four-count, superseding indictment against urologist Hossein Lahiji M.D. and his wife, attorney Najmeh Vahid Lahiji, charging the couple with conspiracy to commit health care fraud, several individual counts of health care fraud, and for conspiring to violate Iranian sanctions.

The health care fraud scheme alleged in this indictment alleges that the defendants submitted false and fraudulent claims in connection with the use of unlicensed and unqualified medical personal and for billing for medical services not rendered. The indictment further alleges they submitted claims for urology services allegedly performed by Dr. Lahiji when, in fact, he was traveling outside Texas and outside the United States. The individuals, who were only licensed as medical assistants, were the ones actually performing these “urology services” without any supervision from any physician or other qualified, licensed personal.  The government also charges Dr. Lahiji with fraud relating to “upcoding,” where he billed for a more comprehensive medical service than was warranted or actually preformed.

According to the DOJ/HHS Annual report, DOJ opened 1,131 new criminal health care fraud investigations in 2012, involving 2,148 potential defendants.  During 2012, federal prosecutors had 2,032 health care fraud criminal investigations pending, involving 3,410 potential defendants, and filed criminal charges in 452 cases involving 892 defendants.  A total of 826 defendants were convicted of health care fraud-related crimes during the year.