Clinic Manager Pleads Guilty In $70 Million Scheme To Defraud Medicare And Medicaid

[nitpicker]

https://www.justice.gov/usao-sdny/pr/clinic-manager-pleads-guilty-70-million-scheme-defraud-medicare-and-medicaid

Department of Justice
U.S. Attorney’s Office
Southern District of New York

FOR IMMEDIATE RELEASE
Monday, February 6, 2017

Clinic Manager Pleads Guilty In $70 Million Scheme To Defraud Medicare And Medicaid

Fraud Ring, With Three Clinics in Brooklyn and Queens, Paid Kickbacks to Individuals to Undergo Medically Unnecessary Tests

Preet Bharara, the United States Attorney for the Southern District of New York, announced that EDUARD ZAVALUNOV, a manager of two health care clinics in Queens, New York, pled guilty today before U.S. District Judge Ronnie Abrams to conspiracy to commit wire fraud, mail fraud, and health care fraud, for his role in a massive health care fraud scheme through which three medical clinics in Brooklyn and Queens submitted over $70 million in fraudulent claims to Medicaid and Medicare.
(snip)

From 2005 to November 2014, ZAVALUNOV, Victor Lipkin, Vadim Zubkov, Nokoloz Chochiev, Anatoliy Fatkhov, Mariana Swaffar, Jacqueline Pinez, Jonathan Oliver, Jason Brissett, Gilbert Trotman, and Giorgi Buleishvili engaged in a scheme to operate three medical clinics in Brooklyn and Queens, through which they recruited financially disadvantaged and homeless people insured by Medicare and/or Medicaid (the “Phony Patients”) to undergo unnecessary medical tests, typically performed by unlicensed personnel, at the clinics in exchange for cash, and then billed the insurers for administering those unnecessary tests. Beginning in or about 2005, Lipkin and Zubkov recruited and paid a particular licensed physician (the “Doctor”) to act as the nominal owner and/or physician under whose name three purported medical clinics would bill Medicare, Medicaid, and private insurance providers (the “Insurance Providers”) for unnecessary services and tests – including sleep tests and stress tests – performed at the clinics. The clinics were located on Avenue V in Brooklyn, New York, and on Hillside Avenue and Elmhurst Avenue, respectively, in Queens, New York. Lipkin and Zubkov were, in fact, the beneficial owners of the clinics, but they concealed their ownership through the Doctor’s nominal affiliation with the clinics, and by laundering the proceeds of the clinics’ operation through shell companies that they owned and controlled. ZAVALUNOV, Lipkin, Zubkov, and Buleishvili operated and controlled the clinics, and ran the clinics’ day-to-day operations, despite the fact that they were not licensed physicians, as required by New York law.

At the direction of ZAVALUNOV, Lipkin, Zubkov, Buleishvili, and other members of the scheme, including Oliver, Brissett, and Trotman (the “Runners”), as well as Chochiev, recruited financially disadvantaged individuals with Medicaid and/or Medicare insurance to act as Phony Patients and undergo unnecessary medical tests at the clinics in exchange for cash payments. The Runners often recruited such individuals from soup kitchens and local welfare offices, and coached them on what to say on various medical forms in order to make it falsely appear that the medical tests to which the defendants intended to subject them were medically necessary. In furtherance of the scheme, Chochiev also made threats of physical violence to individuals who Chochiev believed owed money to the scheme members.

Also in furtherance of the scheme, before the medically unnecessary tests were performed on the Phony Patients, Swaffar and Pinez obtained the Phony Patients’ Medicaid and/or Medicare insurance information, and then contacted the Insurance Providers to confirm that the Insurance Providers would reimburse for the tests. Swaffar and Pinez engaged in such conduct knowing that the Phony Patients were being recruited and paid by the Runners to undergo the tests. Once they determined that a particular Phony Patient’s insurance would pay out claims made by the clinic for the planned medical tests, Swaffar and Pinez notified the Runners that the individuals were eligible and could be brought to the clinic to undergo such tests.
(snip)

[Sherman A1]

1. If the GOP wants to fix Medicare and Medicaid

they could simply fund more enforcement and recovery operations such as this, I suspect that they would likely pay for themselves and result in a great savings to the programs.

[nitpicker]

2. Link to DoJ PR on sentencing

https://www.justice.gov/usao-sdny/pr/clinic-owner-sentenced-manhattan-federal-court-five-years-prison-70-million-scheme