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IN UNITED STATES OF AMERICA v. PATRICK EMEKA IFEDIBA, NGOZI JUSTINA OZULIGBOno. 20-13218, 20-13303, United States Court of Appeals, Eleventh Circuit (August 25, 2022) Patrick Ifediba and Ngozi Justina Ozuligbo appealed his convictions for health care fraud and related crimes. Ifediba, a doctor, ran a clinic called CCMC and employed Ozu-ligbo, a registered practical nurse, there.
Convicted of acting as a pill shop and doubling as insurance fraud
The evidence at trial showed that CCMC prescribed large amounts of opioids to patients who had no medical need for them and ran an allergy testing and treatment scheme that required the insured patients to undergo allergy testing and prescribed them medication despite their negative allergy tests. The clinic billed Medicare and private insurance companies for the tests and treatments.
Ifediba and Ozuligbo were charged with serious counts of health care fraud, conspiracy to commit health care fraud, money laundering of the clinic’s illegal proceeds and conspiracy to commit that crime. Ifediba was charged with illegal distribution of controlled substances without a legitimate medical purpose and for operating CCMC as a “pill mill” to distribute the controlled substances to patients who had no medical need for them.
After a three-week trial featuring testimony from CCMC patients, medical experts and law enforcement officials, the jury convicted Ifediba and Ozuligbo on all counts. The court sentenced Ifediba to 360 months in prison and Ozuligbo to 36 months.
CCMC was operated as a pill mill and required insured patients to undergo allergy testing and treatment.
Ifediba and his wife, Uchenna Ifediba (“Uchenna”), also a doctor, were the only doctors at CCMC. Neither Ifediba nor his wife specialized in pain medication, but they wrote many prescriptions for controlled substance opioids. CCMC attracted patients willing to wait over three hours in a dirty, crowded waiting room to get prescriptions for controlled substances.
In addition to its opioid distribution, CCMC let patients who had insurance into an allergy fraud scheme. The setup was simple. Every insured patient who came to CCMC had to fill out an allergy symptom questionnaire before seeing the doctor. Regardless of the patient’s response, an allergy technician performed a skin prick allergy test on the patient. Whether the test results were positive or negative, Ifediba prescribed immunotherapy to treat allergies and told the technicians to order the medication.
Other patients also failed to receive the immunotherapy treatment that their insurers paid for.
Insurer Blue Cross Blue Shield of Alabama (“BCBS”) noticed the unusually high volume of allergy-related claims from CCMC and announced that it would review the clinic. In preparation for the audit, Ifediba told clinic staff, including Ozuligbo, to change patient records, turn negative allergy test results into positive ones and mark allergy symptoms on patient questionnaires.
A grand jury indicted Ifediba and Uchenna, charging them with multiple counts of unlawful distribution of controlled substances outside the practice of law and without a legitimate medical purpose. They were also charged with conspiracy to distribute the controlled substances and using and maintaining CCMC for the purpose of distributing controlled substances. All of these charges related to the prescription of painkillers. The indictment also charged Ifediba, Uchenna, Ozuligbo and Ebio with conspiracy to commit healthcare fraud through the allergy fraud scheme and substantive counts of healthcare fraud based on specific patient records. It further accused Ifediba, Uchenna and Ozuligbo of laundering the proceeds of the illegal scheme. Uchenna, who suffered a severe stroke, was dismissed from the case as incompetent. Ebio pleaded guilty to one count of conspiracy to commit health care fraud and agreed to testify against Ifediba and Ozuligbo.
The jury heard evidence of health care fraud
The government’s medical expert, Dr. Jim Christensen, told the jury that it was “[a]bcertainly not” appropriate to test patients for allergies just because their health insurance would pay for the test. The court convicted and sentenced the defendants.
The jury returned guilty verdicts for Ifediba and Ozuligbo. The jury convicted Ozuligbo of conspiracy to commit healthcare fraud and material healthcare fraud. Ifediba and Ozuligbo were also found guilty of money laundering the proceeds of the illegal allergy program and conspiring to commit that crime.
The court sentenced Ifediba to 360 months in prison and Ozuligbo to 36 months.
Sufficient evidence supported Ifediba and Ozuligbo’s convictions.
An appellate court must affirm a conviction if there is “no reasonable construction of the evidence” from which the jury could have found the defendant guilty beyond a reasonable doubt. United States v. Garcia405 F.3d 1260, 1269 (11th Cir. 2005).
Patient records were sufficient to support Ifediba’s conviction for felony health care fraud.
The jury convicted Ifediba of 10 counts of substantial healthcare fraud, in violation of 18 USC § 1347(a). To be convicted in a health care fraud case, the defendant must be shown to have known that the claims submitted were in fact false.
For each of the cases Ifediba is challenging, patient records and billing records showed that he or his co-conspirator, Uchenna, ordered treatment knowing it was medically unnecessary. Even though the patients did not need what he prescribed, he still made fraudulent representations to insurers that the patients needed allergy treatment. Testimony confirmed that Ifediba likely knew the treatment was unnecessary but billed insurance companies for it anyway.
The government’s medical expert, Dr. Jim Christensen, testified that it was “inappropriate” to prescribe immunotherapy to someone who tested negative for allergies. The testimony of insurance fraud investigators confirmed that CCMC submitted allergy-related claims for these patients. Additional testimony showed that Ifediba personally signed all the bills that billed Medicare and private insurance companies for the medically unnecessary treatment, defrauding them through false claims.
The paper trail and testimony illustrating Ifediba’s fraudulent representations are enough for a jury; live testimony from patients, although useful, is not required. As a result, the court affirmed the jury’s verdict on the four counts of health care fraud.
Sufficient evidence supported Ozuligbo’s conviction for conspiracy to commit health care fraud.
To sustain a conviction for conspiracy to commit health care fraud in violation of 18 USC §§ 1347 and 1349, the government must establish beyond a reasonable doubt that:
- a conspiracy existed to commit healthcare fraud under 18 USC § 1347;
- the defendant knew of the conspiracy; and
- the defendant knowingly and voluntarily went to it.
Because the crime of conspiracy is “predominantly mental in its composition,” the government can prove these elements by circumstantial evidence and inferences thereof. The government need not prove that the defendant knew all the details of the conspiracy; it need only prove “that the defendant knew the essential nature of the conspiracy.”
There was more than enough evidence to show that CCMC defrauded insurers through an allergy fraud scheme. Patient records showed that Ozu-ligbo knew about the conspiracy to give immunotherapy treatment to patients who had tested negative for allergies.
Ozuligbo’s conversations with Special Agent Bullock support an inference that she knew about the nature of the conspiracy and participated in it. Bullock arranged to meet Ozuligbo at her home for an interview. Standing in her driveway, Ozuligbo told Bullock that she performed allergy tests and administered immunotherapy at CCMC when she used to work there. She told him that CCMC “only did allergy testing and immunotherapy for patients with insurance” because “it was expensive and cash-paying patients wouldn’t pay for it.” On the verge of tears, she told him, “I left there to get away from the madness and all the crazy patients, and now I work for peanuts.” Id. at 58.
From this evidence, the jury could easily have found that Ozuligbo knowingly participated in a conspiracy to bill for medical services that were not actually medically necessary or delivered to the patients.
Ifediba’s sentence was procedurally reasonable.
The court noted the trial evidence illustrating that CCMC supplied controlled substances to people who had no medical need for them. Evidence also showed that Uchenna wrote its share of “bad prescriptions,” CCMC provided an “exponentially higher volume of prescriptions” than other clinics of its size, and the clinic likely engaged in illegal drug distribution before and after the conspiracy period.
The government did not have to prove that each prescription was illegal because the trial showed the clinic was a pill mill that did not serve a legitimate medical purpose. Ample evidence showed that the defendant was aware of its illegitimacy. The district court was upheld on all grounds.
Health insurance fraud, such as that perpetrated by the defendants, has caused the cost of health care for honest, sick or injured people and must be stopped. When the fraud is linked to the distribution of controlled substances to drug addicts and others who had no medical reason for the drugs, doctors break their oath to “first do no harm.” Given the harm done to the public, insurance companies, and government health plans, the sentences were lenient, and when they get out of prison, the defendants will likely live well off the fruits of their crime.
(c) 2022 Barry Zalma & ClaimSchool, Inc.
Barry Zalma, Esq., CFE, now limits his practice to serving as an insurance consultant specializing in insurance coverage, insurance claims management, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He practiced law in California for more than 44 years as an insurance coverage and claims attorney and more than 54 years in the insurance industry. He can be reached at http://www.zalma.com and email@example.com.
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