Guilty pleas in $70M Miami health care fraud scheme

An owner, clinical director, and therapist pleaded guilty to their involvement in a health care fraud scheme involving three Miami mental health centers and $70 million in false Medicare claims. The Department of Justice announced the guilty pleas, which arose from a scheme allegedly involving illegal kickbacks for patient referrals and fraudulent claims submitted to Medicare for costly partial hospitalization program (PHP) services that were not medically necessary or actually provided to patients.

Parties

The scheme involved the owner of R&S Community Mental Health Inc. (R&S) and St. Theresa Community Mental Health Center Inc. (St. Theresa). The owner was also an investor in the New Day Community Mental Health Center LLC (New Day). In addition to the owner, the clinical director of all three clinics and a therapist were allegedly involved in the scheme.

Fraudulent claims

The three community mental health clinics claimed to provide intensive mental health services to Medicare beneficiaries in the Miami area. However, the owner admitted that from 2008 through 2010, the clinics billed Medicare $70 million for PHP services that were not medically necessary or not actually provided to patients. Medicare paid approximately $28 million for the fraudulent claims. The clinical director admitted to overseeing the preparation of false patient records, and the therapist admitted to fabricating patient records to support the false claims for Medicare reimbursement.

Kickbacks

The owner also admitted to paying illegal kickbacks to patient recruiters in exchange for beneficiary referrals to the mental health centers.