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Zalma's insurance fraud letter – May 15, 2019



Braccia, a Pennsylvania physician who co-owned a small network of drug abuse rehabilitation centers, was guilty of signing orders for nearly $ 10 million in unnecessary urine and allergy tests, prosecutors said.

He is also one of 11 people facing state fees following a Pennsylvania statewide grand jury investigation of fraudulent healthcare billing. That investigation is ongoing. In total, Independence Blue Cross was billed for over $ 33 million and paid more than $ 4 million for unnecessary work, according to the Pennsylvania Attorney General Josh Shapiro.

Braccia was a doctor for three departments of drug abuse in Philadelphia called the Liberation Way, records show. According to the records, Braccia signed blank forms for drug testing schemes that were distributed by other non-medical staff.

He often did not evaluate the patients and did not visit any of the three facilities at all court records show.

Liberation Way owners also gave employees cash incentives to ensure that each patient submitted as many samples as their insurance would cover. The Liberation Way actually billed the insurance companies to "unreasonable" amounts, court records said, and the tests were sent to Florida laboratories that kicked back some of the payments to the owners.
The Liberation Way is also allegedly driven a cycle of addiction "treatment" as illegally targeted patients to live in company-owned, unlicensed "sober homes" to increase the amount of treatment time for which it could pay insurers. Patients who returned would return treatment to a higher level of care, resulting in Liberation Way billing for even higher levels of replacement so patients were cycled through treatment as many times as possible, up to eight times.

Court records showed Braccia has already made a payment of $ 1

.2 million in punishment.

A sentence date has not been published.

A New Jersey physician, Ramesh Sarvaiya, was guilty of last month's federal court for its role in the system.

Patient Recruiter Judged for Role in $ 1.6 Million Kickback Scheme

Yamilet Diaz, 50, Hialeah, Florida, was sentenced by US District Judge James I. Cohn in the Southern District of Florida. After a four-day trial in February 2019, which Judge Cohn presided, Diaz was convicted of a number of conspiracies to fight the United States and to have health interruptions and four bills to get health care interruptions.

Diaz, a South Florida Patient Recruiter, was sentenced to 87 months in prison on May 8, 2019 for her role in a system involving about $ 1.6 million in Medicare claims for home care services provided through the payment of backbacks.
According to evidence presented at trial and judicial, from approximately February 2012 to August 2013, Diaz received refunds to refer Medicare recipients to five South Florida home health agencies to serve as patients. The evidence showed that Diaz and her co-conspirators caused Medicare to make over $ 1.6 million in payments to the home health agency based on household service requirements for the recipients recruited by Diaz. The evidence further confirmed that Diaz personally benefited from the fraud and received at least $ 710,000.

Te Kaganovich, 47, and Ramazi Mitaishvili, 58, a married couple , both in Brooklyn, New York, pleaded guilty to a number of medical fraud and a number of conspiracies to avert the IRS's legal functions before US judge Steven M. Gold of the Eastern District of New York. Sentencing has been scheduled for July 18, 2019, before the US district director Margo K. Brodie in the eastern part of New York.

The two New York diagnostic test plant owners pleaded guilty May 8, 2019 for their roles in one more

The respondents were co-owners of several diagnostic testing facilities in Brooklyn, including Sophisticated Imaging Inc., East Coast Diagnostics Inc., East Shore Diagnostics Inc., East West Management Inc. and East West Diagnostics Inc. RM Global Health Inc. As part of its guilty grounds, Kaganovich and Mitaishvili acknowledged that they had implemented a system in which they provided fraudulent health claims for diagnostic testing services.
The defendants admitted that they paid about $ 18.5 million in backbacks for referral of beneficiaries who submitted to diagnostic testing and other alleged medical services. Kaganovich and Mitaishvili incorrectly reported to the IRS that the illegal repayment payments were legitimate business expenses, which meant that the relevant tax rates underestimated corporate income and claimed deductions, they further acknowledged.

Nigerian guilty of role in $ 8.3 Millode Medicare Fraud Scheme

Ayodeji Temitayo Fatunmbi, 47, guilty of a number of conspiracy to commit fraud and a bill of conspiracy to commit money laundering before US District Judge Christina A. Snyder in the Central District of California. Fatunmbi was extradited from Nigeria to the Central District of California in October 2018 on charges in a May 2013 prosecution. Sentencing has been planned for August 19, 2019 before judge Snyder.

The Nigerian man committed guilty on May 8, 2019 for his role in a sustainable medical equipment system that fraudulently billed more than $ 8 million to Medicare for DME It was not medically necessary.

As part of his guilty repentance, Fatunmbi admitted that he and others paid cash shocks to patient recruits and doctors for fraudulent prescriptions for DME, such as power wheelchairs that Medicare recipients did not need. Fatunmbi and co-conspirators caused Lutemi Medical Supply (Lutemi), a DME subsidiary he collaborated to hand in about $ 8.3 million to Medicare, resulting in over $ 3.5 million being paid by the company. Fatunmbi further admitted that he was responsible for $ 2,090,434 in fraudulent and fraudulent medical unnecessary DME claims and that Medicare paid Lutemi to a total of $ 1,076,893. To support this system, Fatunmbi and a co-owner wrote checks from Lutemi's bank account to Lutemi employees and others and Fatunmbi instructed that this money would be returned to him to pay the illegal cash to patient recruits and doctors, he admitted. Fatummbi really directed others at Lutemi to engage in these transactions to hide the nature and source of the revenue from the consumption of health fraud. As part of his appeal agreement, Fatunmbi concluded that he would pay a refund to Medicare in the amount of 1,076,893.

Fatunmbi was accused along with Olufunke Ibiyemi Fadojutimi, 47, Carson, California and Maritza Elizabeth Velasquez, 44, Las Vegas, Nevada . Velasquez pleaded guilty on July 24, 2013 to a number of conspiracy to commit anti-fraud and was sentenced to 15 months' imprisonment and repayment amounting to $ 4,411,428. Fadojutimi found guilty of a jury trial on July 31, 2014 by a number of conspiracy to commit fraud, seven counts of fraud and one count on money laundering and sentenced to four years' imprisonment and repayment in the amount of $ 4,372,466. Fadojutimi, in his judgment, held liability for the entire amount of over $ 8 million in intended losses due to the fraud at Lutemi.


© 2019 – Barry Zalma

This article and all blog posts on this site, digest and summarize cases published by the courts of the various states and the United States. The court decisions have been modified from the court's actual language, simplified to read and convey the author's views in each individual case.

Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage, insurance management, bad faith assurance, and insurance fraud nearly equal for insurers and policyholders. He also serves as an arbitrator or mediator for insurance-related disputes. He practiced law in California for more than 44 years as an insurance cover and law firm and more than 50 years in the insurance industry. He is available at http://www.zalma.com and zalma@zalma.com.

Mr. Zalma is the first recipient of the first annual liability magazine / ACE Legend Award.

Over the past 51 years, Barry Zalma has put his life on insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to enable insurers and their claims to become insurance managers.

A Guide to Liability Compensation

This compact booklet on adaptation of claims is designed to  The Compact Compensation Book Adaptation Second Edition: A Liability Compensation Adjustment Guide gives the new adjustment a basic foundation in what which is needed to become a competent and effective insurance adjuster. It is also available as an update for the experienced adjuster.

The responsibility force teacher quickly learns that there is little difficulty with an applicant (the person claiming bodily injury or property damage against an insured person) if the claim is paid as required. The insured may be unhappy if the claimant's claim is paid as presented because most people do not think they were doing anything wrong or fearing an increase in the premiums for subsequent policy.

The adjuster must be prepared to anoint the insured's feelings, explain why in the law and the policy it was appropriate to pay the creditor and that the settlement is in the best interest of both the insured and the insurer the representative represents.
The adjuster knows and must be prepared to explain to an insured that if a claim is opposed or denied, the plaintiff will be unhappy, will likely be judged. If not settled immediately, the plaintiff's lawyers will claim the insured over the coal to prove that the insured is responsible for the damage. The disputes take time, effort and money to determine the extent of the damage and who is responsible for the damage. Failure to settle immediately may cost the insured his or her reputation and will surely cost the insurer much more than the claim could have been resolved if it had been resolved before the plaintiff retained a lawyer.

Available as a Kindle book

Available as a paperback.


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