The West Miami drug store was called E-Z Pharmacy. A more apt name would have been “E-Z Money.”
The former owners — Eklis Almanza and husband Juan E. Diaz Gonzalez — pocketed $4.8 million from the taxpayer-funded Medicare program by submitting bogus claims for prescription drugs that none of their customers ever needed or received, according to a federal indictment.
In Little Havana, Enemisis Torres is accused of selling forged and altered prescriptions of Medicare patients at her rehabilitation clinic, Palmetto Comprehensive Healthcare, to a ring of Miami-Dade pharmacy owners. They in turn fraudulently billed the federal program $21.2 million, prosecutors say. Her clinic was raided early Thursday.
The defendants are among 73 South Florida suspects charged this week in Miami federal court with bilking Medicare, including dozens accused of defrauding the Part D prescription drug program that was implemented a decade ago during the Bush administration. The total amount of fraudulent claims in the regional sweep: $262 million.
“By stealing from Medicare ... they have robbed all of us,” U.S. Attorney Wifredo Ferrer told reporters Thursday.
The South Florida arrests — carried out by teams of FBI and Health and Human Services agents — are part of this week’s nationwide take-down of 243 Medicare fraud offenders in states across the country, extending to Alaska. The tally of false claims in the nationwide crackdown: $712 million.
The Justice Department in Washington and U.S. attorney's office in Miami held back-to-back news conferences Thursday to spotlight the latest schemes to fleece the Medicare program, which continues to be plagued by billions of dollars in losses to fraud every year.
Ferrer called the latest healthcare fraud take-down the “largest ever” over the past decade, with Miami, the capital of Medicare fraud, accounting for one-third of all defendants charged this week. “It’s unacceptable, staggering and pretty shocking,” he said.
FBI special agent in charge, George Piro, said rampant Medicare fraud is “leaving people with legitimate healthcare needs to bear the burden” and forcing law enforcement to “devote vast resources to investigate” this perpetual problem.
In a statement, Piro also took Medicare bureaucrats to task: “To attack the problem from both ends, tougher regulations and oversight are key to reducing the amount of fraud from occurring in the first place.”
Since its inception in 2006, the Part D program has gained popularity because it helps deliver prescription drugs to nearly 40 million elderly and disabled Americans, who buy them from pharmacies reimbursed by private insurers funded by Medicare. But predictions of potential fraud in the program — which accounts for just over 10 percent of Medicare spending — have turned out to be accurate because numerous pharmacies submit false prescriptions for anti-depressant, anti-inflammatory and other drugs.
In several of the latest criminal cases in Miami, pharmacy owners paid kickbacks to patients or patient recruiters to generate a steady stream of bogus Medicare claims to bilk the Part D program. That has been a longstanding practice in South Florida’s Medicare rackets, which have billed for a host of unused services from medical equipment to HIV infusion therapy to mental health sessions.
Among the 38 South Florida criminal cases filed this week, some clinic operators also sold batches of fabricated prescriptions that Medicare patients didn’t even know about — distributing them like a “drive-thru” business, authorities say, to be used for filing fraudulent claims.
In 2013, ProPublica reporters highlighted the vulnerability of the Part D program, noting that insurance companies must pay for prescriptions issued by any licensed prescriber and filled by any willing pharmacy within 14 days.
“Insurers generally must cover even suspicious claims before investigating, an approach called ‘pay and chase,’’’ the online, investigative news organization reported. “By comparison, these same insurers have more time to review questionable medication claims for patients in their non-Medicare plans.”
At Thursday’s news conference in Miami, the criminal chief of Health and Human Services’ Office of Inspector General said that increasingly offenders are trying to rip off both public and private health insurance programs.
“The fraudsters are targeting our tax dollars and they are also targeting private dollars,” said HHS-OIG special agent in charge, Shimon Richmond.
He and other officials noted there has been an “uptick” in fraud cases against private health maintenance organizations that have increasingly played a bigger role in managing federal Medicare and state Medicaid benefits.
Washington, D.C., attorney Kirk Ogrosky, who worked as a senior federal healthcare fraud prosecutor in Miami and the Justice Department, said there should be greater accountability in paying Medicare claims — whether they are reviewed by government contractors or private insurers.
Ogrosky said the latest series of Part D criminal prosecutions should help slow the spread of prescription drug scams. “I predict these Part D cases will have an immediate impact, as people running fraud schemes in this area are not used to seeing arrests and prosecutions.”