Each year, phony Medicare claims filed by durable medical equipment suppliers, home health care agencies, pharmacies, physicians, and assisted living and rehabilitation facilities defraud the federal government of billions of dollars.
In Florida, which has the nation’s highest proportion of residents over the age of 65, schemes to bilk the federal health insurance program are rampant, with the Miami area considered ground zero for health care fraud.
That’s where two special agents from the Department of Health and Human Services (HHS), Omar Pérez Aybar and Reginald J. France, have come into the picture. In partnership with Joseph Beemsterboer, Dan Bernstein, Randy Culp and Joseph Jeziorski from the Department of Justice (DOJ), Aybar and France coordinated investigations for 12 special Healthcare Fraud Enforcement Action Teams (HEAT).
From 2008 through June 2014, these teams have racked up 857 indictments and 685 convictions and returned nearly $1 billion to the Medicare Trust Fund.
No other jurisdiction in the country has matched this record.
“The number of cases and people affected is nothing less than amazing,” said Joan Silverstein, chief of the Economic and Environmental Crimes Section in the U.S. Attorney’s Office in Miami.
France and Aybar are engaged in every aspect of their squads’ work and are experts on Medicare regulations. They supervise agents and approve investigatory strategies, including issues like search warrants, the need for bank records and surveillance. They work closely with the U.S. Attorney’s Office and the FBI, brief headquarters in Washington and provide oversight to make sure the inquiries are on the right path.
“Reggie and Omar work tirelessly every day to make sure that our prosecutors have what they need. They foster a professional environment that allows us to get a return on taxpayer dollars,” said Joseph Beemsterboer, assistant chief of the fraud section of DOJ’s Criminal Division. “They are extremely effective managers of their line agents, and they play an active role in all investigations.”
What’s more, the HEAT teams in Miami established a highly successful template for combating Medicare fraud that Aybar and France have shared with other regions of the country. The teams’ success led eight additional federal judicial districts to form their own HEAT teams. They now operate in Baton Rouge, La., Brooklyn, N.Y., Chicago, Dallas, Detroit, Houston, Los Angeles, and Tampa, Fla.
The Miami teams have made a huge dent in Medicare claims related to durable medical equipment, where billings dropped from $6.1 billion when the investigations first began to $2 billion in early 2014. They also took down many fraudulent community mental health scams, reducing billings in that area from $70 million to about $10 million per quarter since the crackdown started.
In 2013, for example, the owner of a Miami mental health clinic and three other participants received prison sentences for filing $50 million in false and fraudulent claims to Medicare. The Miami task force led by France and Aybar developed evidence that the defendants paid patient recruiters to refer ineligible Medicare beneficiaries to the clinic for services that were never provided or were not reimbursable under applicable Medicare rules.
In another case, the owner of a home health agency in Miami was sentenced to 10 years in prison and ordered to pay $26 million in restitution after pleading guilty to charges of conspiracy to commit health care fraud. The individual claimed to have provided home health care services to beneficiaries when, in fact, the patients were not homebound and had no medical necessity for the services.
Aybar, a 16-year HHS employee, joined HEAT when it originated as a pilot program in 2007. His motivation stems from understanding the importance of the Medicare program and the impact that the fraud has on the Medicare Trust Fund and the ability to provide needed health care services.
France, a 17-year law enforcement officer formerly with the Immigration and Naturalization Service and the Department of Energy, joined HEAT in 2011. He said personal outrage feeds his drive to identify and prosecute unscrupulous operators.
“Poor people and elderly people are being directly impacted by these crimes,” said France. “We are talking about a multibillion-dollar program that helps people who really need it, and these crimes are siphoning that money away.”