MIAMI-BASED HEALTH CARE CLINIC SENTNECED IN $50 MILLION FRAUD SCHEME

FROM: U.S. DEPARTMENT OF JUSTICE
Friday, April 5, 2013
Miami-Based Health Care Clinic and Its Owners and Operators Sentenced for $50 Million Fraud Scheme

The owners and operators of Biscayne Milieu, a Miami-based mental-health clinic, and the clinic itself were sentenced today for their participation in a Medicare fraud scheme involving the submission of more than $50 million in fraudulent billings to Medicare, announced Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Michael B. Steinbach, Special Agent in Charge of the FBI’s Miami Field Office; and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Office of Investigations Miami Office.

Antonio Macli, 73, Jorge Macli, 41 and Sandra Huarte, 49, all of Miami, and Biscayne Milieu were sentenced by U.S. District Judge Robert N. Scola Jr. in the Southern District of Florida. Antonio Macli was sentenced to serve 360 months in prison; Jorge Macli was sentenced to serve 300 months in prison; and Huarte was sentenced to serve 262 months in prison. In addition, Biscayne Milieu, the corporate entity these defendants controlled, was sentenced to one year of probation. In addition to their prison terms, Antonio Macli, Jorge Macli and Huarte were each sentenced to serve three years of supervised release. Restitution payments for each of the defendants will be determined on April 25, 2013.

The defendants were each convicted on Aug. 24, 2012, of conspiracy to commit health care fraud, at least one substantive count of health care fraud, and conspiracy to offer and pay kickbacks following a two-month jury trial. Antonio and Jorge Macli and Huarte were also each convicted of conspiracy to commit money laundering and substantive money laundering counts at trial.

According to the evidence at trial, Biscayne Milieu was a closely held, family-run fraudulent clinic that was owned by Antonio Macli and his son Jorge Macli. Antonio Macli’s daughter Sandra Huarte was an executive at the clinic. Together the defendants created and oversaw a scheme in which they, along with their co-defendants, submitted over $50 million in false and fraudulent claims to Medicare through Biscayne Milieu, which purportedly operated a partial hospitalization program (PHP) – a form of intensive treatment for severe mental illness. Instead, the defendants devised a scheme in which they paid patient recruiters to refer ineligible Medicare beneficiaries to Biscayne Milieu for services that were never provided or that were not reimbursable under applicable Medicare rules. Many of the patients admitted to Biscayne Milieu that they were not eligible for PHP treatment because they were chronic substance abusers, suffered from dementia and would not benefit from group therapy, or were not mentally ill and were procuring false diagnoses of mental illness in order to obtain exemptions from the civics portion of the U.S. citizenship application.

The evidence at trial further showed that Antonio and Jorge Macli and Huarte collectively paid patient recruiters more than $1 million in illegal kickbacks to recruit Medicare patients who were ineligible for PHP treatment. Biscayne Milieu then billed Medicare for tens of millions of dollars in PHP treatments for these patients. Antonio and Jorge Macli and Huarte also hired doctors, therapists and other health care professionals to further their massive illegal scheme. Along with co-conspirators working at their direction, they created falsified medical records intended to conceal their Medicare fraud and phony "case manger" contracts in an attempt to hide their extensive illegal kickbacks.

Antonio Macli was the initiator of the fraud scheme, enlisted his son and daughter to participate in it and had primary control over the clinic’s bank accounts that received money stolen from Medicare that was then used to pay illegal kickbacks.

Jorge Macli was most responsible for the clinic’s day-to-day operations and took steps, on a daily basis, to conceal and further the fraud, including deflecting complaints from patients and staff and paying bribes to patients in exchange for their silence.

Huarte oversaw both the kickback payments and the Medicare billings for the clinic. Huarte ensured that Biscayne Milieu’s fraudulent claims could pass scrutiny by Medicare by creating fraudulent paperwork and medical files, and soliciting other employees to do the same, so that these false claims were paid.

Evidence further revealed that Antonio and Jorge Macli and Sandra Huarte engaged in a sophisticated scheme to use a series of ostensibly legitimate corporations to conceal and launder Biscayne Milieu’s fraudulent profits.

Various owners, doctors, managers, therapists, patient brokers and other employees of Biscayne Milieu have also been charged with various health care fraud, kickback, money laundering and other offenses in two indictments unsealed in September 2011 and May 2012. Biscayne Milieu, its owners, and more than 25 of the individual defendants charged in these cases have pleaded guilty or have been convicted at trial.

The case is being prosecuted by Assistant U.S. Attorneys for the Southern District of Florida Michael Davis, Marlene Rodriguez and James V. Hayes. Hayes was formerly a Trial Attorney in the Criminal Division’s Fraud Section. The case was investigated by the FBI with the assistance of HHS-OIG, and was brought by the U.S. Attorney’s Office for the Southern District of Florida in coordination with the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,480 defendants who have collectively billed the Medicare program for more than $4.8 billion. In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers.

HHS SECRETARY CALLS ON HEALTH INSURANCE COMPANIES TO STOP UNREASONABLE RATE HIKES

The following excerpt is from the Department and Human Services website:
Health insurance rate hikes in nine states deemed excessive by HHS
Secretary Sebelius calls on insurance companies to drop unreasonable rate hikes
Health and Human Services (HHS) Secretary Kathleen Sebelius announced today that health insurance premium increases in nine states have been deemed “unreasonable” under the rate review authority granted by the Affordable Care Act.

"Thanks to the Affordable Care Act consumers are no longer in the dark about their health insurance premiums," said Secretary Sebelius.  "Now, insurance companies are required to justify rate increases of 10 percent or higher.  It’s time for these companies to immediately rescind these unreasonable rate hikes, issue refunds to consumers or publicly explain their refusal to do so."

Secretary Sebelius also released a new report today showing that, six months after HHS began reviewing proposed health insurance rate increases, consumers are already seeing results.  Since the rate review program took effect in 2011, health insurers have proposed fewer double-digit rate increases. Furthermore, more states have taken an active role in reducing rate increases, and consumers in all states are getting straight answers from their insurance companies when their rates are raised by 10 percent or more.  As of March 10, 2012, the justifications and analysis of 186 double-digit rate increases for plans covering 1.3 million people have been posted at HealthCare.gov, resulting in a decline in rate increases.  According to the report, in the last quarter of 2011 alone, states reported that premium increases dropped by 4.5 percent, and in states like Nevada, premiums actually declined.

In the decisions announced today, HHS determined, after independent expert review, that two insurance companies have proposed unreasonable health insurance premium increases in nine states—Arizona, Idaho, Louisiana, Missouri, Montana, Nebraska, Virginia, Wisconsin, and Wyoming.  The excessive rate hikes would affect over 42,000 residents across these nine states.
In these nine states, the insurers have requested rate increases as high as 24 percent. These increases were reviewed by independent experts to determine whether they are reasonable.  In this case, HHS determined that the rate increases were unreasonable, because the insurer would be spending a low percentage of premium dollars on actual medical care and quality improvements, and because the justifications were based on unreasonable assumptions.

Most rates are reviewed by states and many states have the authority to reject unreasonable premium increases.  Since the passage of the health care law, the number of states with this authority increased from 30 to 37, with several states extending existing “prior authority” to new markets.
The report released today shows that:
States like Texas, Kentucky, Nevada and Indiana are reporting fewer requests for rate increases over 10 percent.

States like California, New York, Oregon, and many others, have proactively lowered rate increases for their residents.

The rate review program has made insurance companies explain their increases, and more than 180 have been posted publicly and are open for consumer comment on companyprofiles.healthcare.gov.
This initiative is one of many in the health care law to ensure that insurance companies play by the rules, prohibiting them from dropping coverage when a person gets sick, billing consumers into bankruptcy through annual or lifetime limits, and, soon, discriminating against anyone with a pre-existing condition.

BLUE CROSS BLUE SHIELD OF TENNESSEE SETTLE POTENTIAL HEALTH CARE RULE VIOLATIONS

The following excerpt is from a U.S. Department of Health and Human Services e-mail:
Blue Cross Blue Shield of Tennessee (BCBST) has agreed to pay the U.S. Department of Health and Human Services (HHS) $1,500,000 to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules, Leon Rodriguez, Director of the HHS Office for Civil Rights (OCR), announced today.  BCBST has also agreed to a corrective action plan to address gaps in its HIPAA compliance program.  The enforcement action is the first resulting from a breach report required by the Health Information Technology for Economic and Clinical Health (HITECH) Act Breach Notification Rule.