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Medical biller sentenced to 45 months in prison for role in $4 million health care fraud scheme

The medical biller of a Chicago-area visiting physician practice was recently sentenced to 45 months in prison for her role in a $4 million health care fraud scheme.

Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, U.S. Attorney Zachary T. Fardon of the Northern District of Illinois, Special Agent in Charge Lamont Pugh III of the U.S. Department of Health, and Human Services-Office of Inspector General (HHS-OIG) in Chicago and Acting Special Agent in Charge John A. Brown of the FBI’s Chicago Division made the announcement.

The medical biller was convicted in May 2015 following a jury trial of one count of conspiracy to commit health care fraud, six counts of health care fraud, and three counts of false statements relating to a health care matter. In addition to imposing the prison term, U.S. District Judge Gary Feinerman of the Northern District of Illinois ordered the defendant to pay approximately $1 million in restitution.

From 2007 to 2011, the defendant was the primary medical biller at a physician practice that visited patients in their homes and prescribed home health care.  The evidence at trial showed that the defendant and her co-conspirators routinely billed Medicare for overseeing patient care plans (a service known as “care plan oversight” or CPO) when, in fact, the doctors at the practice rarely provided the service. 

The evidence at trial also showed that the defendant and her co-conspirators billed Medicare for other services that were never provided, including services rendered to patients who were deceased, services purportedly provided by medical professionals no longer employed by the practice, and services purportedly provided by medical professionals who, based on billing records, worked over 24 hours per day.

According to the evidence presented at trial, during the five-year conspiracy, the practice submitted bills to Medicare for more than $4 million in services that were never provided. Medicare paid more than $1 million on those claims.

The defendant’s two co-conspirators, one of whom is the practice’s medical director, were also convicted of offenses based on their roles in the scheme. 

The case was investigated jointly by HHS-OIG and the FBI, and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office of the Northern District of Illinois. The case was prosecuted by Trial Attorney Brooke Harper and Senior Trial Attorney Jon Juenger of the Criminal Division’s Fraud Section.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 2,300 defendants who collectively have billed the Medicare program for over $7 billion. In addition, the HHS Centers for Medicare & Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

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