White Collar Criminal Defense Group

DOJ Continues Its Focus On False Claims In Mental Healthcare

Mental health care providers should be mindful that DOJ has maintained its vigilance in pursuing false claims cases against mental health care providers when evidence calls into question the extent of services provided or demonstrates that the claimed services were not medically necessary.  The most recent example is the case of Santiago Borges, Erik Alonso, and Cristina Alonso, all of whom entered pleas of guilty last Wednesday in the U.S. District Court for the Southern District of Florida to charges relating to false claims for mental health care purported to have been provided at three Miami area clinics. 

According to the government, Borges owned the now-defunct mental health centers R&S Community Health, Inc. (R&S) and St. Theresa Community Mental Health Center, Inc. (St. Theresa), and was an investor in New Day Community Mental Health Center, LLC (New Day).  Eric Alonso was the clinical director of all three centers, and Cristina Alonso was a therapist at R&S.  As with other recent mental health care prosecuted by DOJ, the government zeroed in on claims by the clinics that they provided “intensive” mental health services.  According to the government, the clinics billed Medicare for costly Partial Hospitalization Program (PHP) services that were not medically necessary or not provided to patients. 

The government claimed that from 2008 through 2010, the three defendants were involved with causing the clinics (R&S, St. Theresa and New Day) to bill for procedures that were not provided to patients.  Borges admitted that he paid kickbacks to patient recruiters who, in exchange, referred beneficiaries to the centers.  Eric Alonzo admitted that he oversaw the preparation of false patient records.  Cristina Alonzo admitted that she fabricated patient records, including group therapy session notes that were used to support claims for reimbursement from Medicare.  The total of the fraudulent claims submitted was more than $70 million, and, according to the government, Medicare paid approximately $28 million on those claims.

Borges pleaded guilty to conspiracy to commit healthcare fraud and conspiracy to defraud the United States and pay healthcare kickbacks.  Eric Alonzo pleaded guilty to conspiracy to commit healthcare fraud and conspiracy to make false statements related to healthcare matters, and Cristina Alonzo pleaded guilty to conspiracy to commit healthcare fraud and conspiracy to make false statements relating to healthcare matters.

A fourth defendant, Damien Mayol, has thus far maintained his plea of not guilty.  Mayol, the owner of a Florida-based transportation service provider, was also charged in the same indictment with healthcare fraud relating to the payment of kickbacks to patient recruiters. 

The case is similar to the recent series of convictions in Houston, Texas, of individuals involved with the operation of Riverside General Hospital, and claims for PHP services.  In that case, 13 individuals have been convicted through guilty pleas or trial, including former Riverside president, Earnest Gibson, III, who was sentenced in June to 45 years in prison. 

DOJ Settles Civil Medical Necessity Claims With Health System While Orthopedic Surgeon Remains A Fugitive From Criminal Charges

On Friday, the DOJ announced it had reached an agreement with an Ohio health system to settle allegations of violations of the False Claims Act for costs resulting from medically unnecessary procedures performed at one of the system’s hospitals.  Under the agreement, Cincinnati-based West Chester Hospital and its parent company, UC Health, will pay $4.1 million to settle claims that West Chester billed the government for medically unnecessary procedures performed by orthopedic surgeon Abubakar Atiq Durrani, M.D

According to the government, the false claims consisted of hospital charges for spine surgeries performed by Dr. Durrani between 2009 and 2013.   At the time of the announcement of the settlement, Principal Deputy Assistant AG Benjamin C. Mizer distinguished the responsibility of the hospital from that of the surgeon, saying that “hospitals have the responsibility to ensure that services provided at their facilities are medically necessary and appropriate before they bill federal healthcare programs for those services.”

The government has charged Dr. Durrani criminally, alleging that he intentionally made false claims and false statements in relation to cervical, thoracic and lumbar surgeries.  After being arraigned on those criminal charges in 2013, Dr. Durrani reportedly fled to his native Pakistan, and remains a fugitive.  The pending criminal charges include several sensational allegations of bogus surgical recommendations made by Dr. Durrani to patients.  This included allegations that Dr. Durrani falsely informed patients that their conditions were surgical emergencies when they were not, and going further in some instances by telling patients they were at risk for paralysis or that a patient’s head would fall off if the patient were in a car accident because there was nearly nothing holding it on.

Dr. Durrani is also the subject of more than 250 civil malpractice claims by former patients, including one that went to trial shortly after Durrani fled the country and resulted in a judgment in the amount of $750,000.  Another such case went to trial in 2014 and actually resulted in a verdict in his favor.  The hospital has denied allegations by many of the plaintiffs that it was at fault for failing to scrutinize Dr. Durrani’s credentials, which some plaintiffs allege were falsified