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Thursday, April 28, 2016

Twenty-Five Miami-Area Defendants Charged with Submitting $26 Million in False Claims to the Medicare Part D Program

Charges were filed today against 25 Miami-area defendants in three separate cases for their alleged participation in various schemes to defraud Medicare of approximately $26 million in false claims through the Medicare Part D program. 

Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida, Assistant Special Agent in Charge William J. Maddalena of the FBI’s Miami Division and Special Agent in Charge Shimon R. Richmond of the U.S. Department of Health and Human Services-Office of Inspector General’s (HHS-OIG) Miami Regional Office made the announcement.

“These cases build on our recent efforts to focus on Medicare prescription drug benefit fraud, targeting those who take advantage of the fastest-growing component of the Medicare program,” said Assistant Attorney General Caldwell.  “Working with our partners in the Medicare Fraud Strike Force, the Criminal Division uses cutting-edge data analysis techniques to identify emerging fraud schemes and to stay ahead of the criminal curve.”

“Those who commit Medicare fraud through the filing of false claims, payment or receipt of kickbacks, or fraudulent medical practices jeopardize the integrity of the government benefit programs that countless citizens rely on for their well-being,” said U.S. Attorney Ferrer.  “The U.S. Attorney’s Office and our law enforcement allies will continue to pro-actively identify for prosecution the individuals who pay kick-backs for the unauthorized use of Medicare benefits for their own illicit financial gain.”

“The actions of the FBI and our partners in the Medicare Fraud Strike Force have disrupted several health care fraud operations today,” said Assistant Special Agent in Charge Maddalena.  “Unfortunately, South Florida remains ground zero for these types of scams.  As such, we will continue to pursue those individuals who pay kickbacks and fraudulently bill for medical services that are not necessary or ever provided.”

“A dangerous trend is fraudulent pharmacy billing for drugs,” said Special Agent in Charge Richmond.  “But exploitation of the Medicare prescription drug benefit will not be tolerated and suspects will face aggressive investigation and prosecution.”

United States v. Antonio Hevia et al. charges 18 defendants for their participation in a scheme to defraud the Medicare Part D program through false claims from eight separate Miami-Dade County area pharmacies.  The defendants each face various charges from among the following offenses included in the indictment:  conspiracy to commit health care fraud and wire fraud; substantive counts of health care fraud; and conspiracy to defraud the United States and pay and receive health care kickbacks.  The indictment alleges that the fraud scheme was orchestrated by Pedro Torres, 43, of North Bay Village, Florida, and Antonio Hevia, 53, of Miami, who recruited individuals to be the owners of pharmacies in Miami-Dade County, which were then used to submit false and fraudulent claims to the Medicare Part D program.  Hevia and Torres allegedly controlled pharmacies that were used to facilitate the fraudulent scheme, including:  Sun View Pharmacy, K.A.R. Pharmacy, Lola Pharmacy, Latin Quarters Drug Store, Lily and Rosy Pharmacy, Norton Pharmacy, Health Star Pharmacy and Supply, Ultra Medical Services and OMG Pharmacy Discount.  Torres and Hevia allegedly instructed the staff at the respective pharmacies to submit false and fraudulent claims for millions of dollars for prescription drugs that were not medically necessary and not provided to the Medicare Part D beneficiaries.  Medicare beneficiaries were frequently referred to the pharmacies by patient recruiters, who received kickbacks for referring patients.  The 18 co-conspirators are charged as owners and/or patient recruiters in the fraudulent scheme.  As a result of the filing of false and fraudulent claims, Medicare made approximately $16.7 million in payments. 

Assistant U.S. Attorney James Hayes of the Southern District of Florida is prosecuting this case.

United States v. Kenia Gonzalez et al. charges Julio Espinosa Moret, 40; Kenia Gonzalez Fernandez, 41; Frank Dunier Perez, 39; and Luzbella Nunez de la Torre, 47, all of Miami, with conspiracy to defraud the United States and pay and receive kickbacks and for receiving kickbacks.  The indictment alleges that the defendants solicited and received kickbacks and bribes to recruit Medicare beneficiaries and induce the Medicare beneficiaries to obtain prescriptions for pharmaceutical drugs to be used in conjunction with the submission of claims to the Medicare Part D Program through OMG Pharmacy.  

Trial Attorney Vasanth Sridharan of the Criminal Division’s Fraud Section is prosecuting this case.

United States v. Ronald Diaz, et al. charges Ronald Diaz, 28, Mercedes Maya, 30, and Gladys Cabrera, 28, all of Miami, with various charges, including conspiracy to commit health care fraud, health care fraud and money laundering.  The indictment alleges that Diaz is the named owner of Total Pharmacy, New Life Community Pharmacy, La Botica Pharmacy, La Botica Pharmacy No 02, Solutions Drug Store, M & P Pharmacy, La Roca Pharmacy and Richard’s Pharmacy Discount, pharmacies located in Miami-Dade County, that purportedly provided prescription drugs to Medicare beneficiaries.  Diaz, Maya and Cabrera allegedly submitted and caused the submission of claims via interstate wires that falsely and fraudulently represented that various health care benefits, primarily prescription drugs, were medically necessary, prescribed by a doctor and had been provided by these pharmacies to Medicare beneficiaries.  As a result of these claims, Medicare prescription drug plan sponsors, through their pharmacy benefit managers, made approximately $10,428,019 in payments that were funded by the Medicare Part D program to the pharmacies.

Assistant U.S. Attorney Christopher Clark of the Southern District of Florida is prosecuting this case. 

The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 by the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.  Since its inception in March 2007, the Medicare Fraud Strike Force has charged over 2,300 defendants who have collectively billed the Medicare program for more than $7 billion.  In addition, the HHS Centers for Medicare & Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

In the Southern District of Florida, nearly 900 individuals have been charged for their involvement in more than $2.5 billion in fraudulent Medicare billings.

Part D prescription medicine coverage is the fastest-growing area of the Medicare program.  Last year alone, more than $120 billion was spent on the Medicare Part D program, up from $78 billion in 2010.  Based on U.S. Government Accountability Office estimates, as much as $10 billion of last year’s $120 billion in Medicare Part D spending may be fraudulent.  The Department of Justice, along with its law enforcement partners, is committed to aggressively targeting Part D fraud. 

The Medicare Fraud Strike Force investigated the various cases with assistance from the FBI and HHS-OIG.   

An indictment is merely an allegation, and all defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law.    

To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to www.stopmedicarefraud.gov.

Hevia et al Indictment

Fernandez et al Indictment

Diaz et al Indictment

Healthcare Fraud
Updated April 28, 2016