The Eleventh Circuit Court of Appeals denied an appeal and upheld the convictions of a physician assistant and a patient recruiter in Florida for their actions in allegedly defrauding the Medicare program of $200 million in false claims. Both the physician assistant, Roger Bergman, and the patient recruiter, Rodolfo Santaya, worked for American Therapeutic Corporation based out of Miami. ATC provides psychiatric care for patients with mental illness.
Bergman was alleged to have submitted false claims to the Medicare program by falsifying patient documents to make it appear that the patients were eligible for the programs offered at ATC, but in fact they were not. In addition, Bergman submitted false patient documentation that stated Medicare-eligible care was given to patients when no such services were ever provided. Claims for payment from the Medicare program for false or ineligible services were billed by ATC and paid out to the company. Santaya’s alleged role in the fraud scheme was to go to low-income neighborhoods, apartment complexes, and retirement homes to recruit disabled or elderly patients to ATC, receiving up to a $45 kickback for each patient obtained. The patients brought in by Santaya would be ineligible for the outpatient psychiatric care provided by ATC or did not even have medical needs necessitating psychiatric care at all. Santaya was alleged to have focused only on Medicare beneficiaries in his recruitment efforts and instructed the patients to lie about their symptoms in order to administer billable services to them. The subject convictions and sentences affirmed by the Eleventh Circuit are 15 years for Bergman and 12 years for Santaya.
Medicare fraud continues to burden the Federal government and taxpayers, resulting in tens to hundreds of billions of dollars of loss each year. The Medicare Fraud Strike Force is a multi-agency team of investigators and prosecutors whose sole purpose is to investigate suspicious Medicare and Medicaid billings through data analysis and community reporting and prosecute those engaging in such fraud and abuse of government health programs. As of June 2016, the Medicare Fraud Strike Force has gained 2,185 indictments and retrieved $1.98 billion  in their efforts to combat Medicare fraud. Healthcare professionals that are accused and subsequently found in violation of federal and state laws governing fraud face severe adverse consequences that may include substantial fines, jail time, loss of medical licenses and exclusion from future Federal health care programs. The best defense against such convictions and subsequently their consequences is to have a medical practice with proper policies and procedures in place to prevent violations of government reporting and reimbursement requirements. In any medical practice or other healthcare business, thorough documentation of all services provided, all payments received and paid out, and all financial relationships between a practice and other medical companies or providers are a critical part of reducing the risks of noncompliance with applicable laws and regulations.
Hamil Little PC
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