Home Health & Hospice Week

Surprise! The person paying kickbacks may be working for the FBI.

Anew fraud case alleging kickbacks for certifying ineligible patients for home health and hospice services has caught mainstream press attention, mainly because the physician indicted is also the mayor of a South Texas town.

Rodney Mesquias owned and controlled the Merida Health Care Group, a collection of health care entities throughout Texas that provides hospice and health care services, the Department of Justice says in a release. Henry McInnis and Jose Garza helped control, manage, and oversee Mesquias's various entities, and licensed physician Francisco Pena was Merida's medical director.

In a fraud conspiracy involving more than $150 million in false Medicare claims, "Mesquias, McInnis, and Garza caused kickbacks and bribes to be paid to medical directors, including Pena, for the Merida Group's affiliated entities in exchange for certifying that patients qualified for services when, in fact, they did not, and for referring patients for such services," the DOJ claims. "Mesquias, McInnis, Garza, and Pena also fraudulently kept patients on hospice services for multiple years in order to increase revenue from Medicare."

The defendants laundered the proceeds from the scheme, prosecutors allege. And "Mesquias and McInnis used proceeds derived from the scheme to purchase expensive vehicles such as a Porsche, expensive jewelry, luxury clothing from high-end retailers such as Louis Vuitton, exclusive real estate and season tickets for premium seating to see the San Antonio Spurs," according to the release.

Pena is also accused of giving a false statement to the FBI and obstructing the investigation. A "confidential source" (CS) allegedly paid Pena a total of $5,000 in cash kickbacks for illegal referrals of hospice patients, but when Pena was interviewed by the FBI, he denied ever accepting kickbacks in exchange for patient referrals. "After the FBI interview, Pena then allegedly contacted the CS and directed the CS to mislead the FBI in the event that the CS was interviewed about the cash kickbacks," the DOJ says.

Plus: "During the course of the investigation, Pena allegedly told a cooperating witness that, with respect to hospice patients, 'the way you make money is by keeping them alive as long as possible,'" the DOJ says.

When a federal grand jury subpoenaed Merida's records, Mesquias and McInnis "allegedly instructed their co-conspirators to manufacture false records ... to obstruct the grand jury's investigation," the DOJ adds.

Residents of Rio Bravo have united to ask the Webb County Attorney to remove Pena from office, KGNS reports. Pena's four-year term as mayor is scheduled to end this year.

Other recent home health and hospice fraud case developments include:

In New Orleans: A patient recruiter has drawn a four-year prison term for her conviction in a Medicare home health fraud scheme centering on mentally ill patients. In September 2017, a federal jury convicted Kim Ricard on kickback and fraud charges (see Eli's HCW, Vol. XXVI, No. 34).

Ricard and others "engaged in a scheme to refer mentally ill Medicare patients to home health agencies in and around New Orleans, in exchange for kickbacks," the Justice Department says in a release. Prosecutors showed that Ricard illegally used the Medicare identification information of three Medicare beneficiaries and lied to investigators. As a result, Ricard's co-conspirator caused Medicare to pay more than $1.9 million based on those illegally obtained referrals, according to the DOJ.

In addition to the prison term, Ricard must pay nearly $2 million in restitution, the DOJ says.  Another defendant in the case, Milton Diaz, pled guilty in July 2017 and is awaiting sentencing, the DOJ says.

In Dallas: Last month, a husband and wife were indicted on charges that they submitted false claims for home health services and defrauded Medicare of more than $3.4 million, the DOJ says in a release.

Edwin Oparaochaekwe and Chiazom Oparaochaekwe, owners of Prime World Home Health in Mansfield, Texas, direct-marketed home health services to Medicare beneficiaries, then "sought and obtained signatures on CMS-485s from physicians who had no prior relationship with the patients, and who, in many cases, never saw or treated them," the DOJ alleges. "The defendants sought home health certifications for patients regardless of the patient's eligibility."

The Oparaochaekwes directed Prime World employees to submit claims for patients that did not have legitimately signed CMS-485s, the DOJ adds. For some of the unsigned CMS-485s, RN Chiazom Oparaochaekwe "forged the signatures by photocopying physician signatures and affixing them on the unsigned document. Chiazom Oparaochaekwe then placed a copy of the forged document in the patient's medical record," according to the DOJ.