Elite Miami Mogul Accused of $1 Billion Nursing Home Fraud

It’s hard to imagine someone treating nursing home patients like livestock, herding them from one facility to the next for $1 billion in profit, but that’s precisely what mogul, Philip Esformes is accused of doing. Esformes is a businessman who lived a comfortable, luxurious lifestyle until the FBI arrested him for the country’s largest nursing home fraud scheme in history.

Defrauding Government Assistance for Nursing Homes

Philip Esformes is currently undergoing trial in Florida after being charged by the federal government for health care and nursing home fraud, money laundering, conspiracy and obstruction. Esformes’s $1 billion scheme moved patients throughout his network of seven nursing homes and nine assisted living facilities for the sole sake of maximizing profits.

In his scheme, patients would spend their first 100 days at one of Esformes’s nursing homes where Medicare would foot the bill, covering the cost of skilled nursing services. When government assistance ended, Esformes would relocate patients to one of his assisted living facilities.

From there, patients would be transferred back to a hospital. Esformes would then bribe doctors for another referral to acquire another 100 days of nursing services.

“It happened over and over again. Rinse and repeat,” said Elizabeth Young, prosecutor for the case.

Two other people involved in the fraud, hospital director Odette Barcha and a physician’s assistant named Arnaldo Carmouze have already pled guilty to their roles in Esformes’s evil scheme.

Bribing Doctors and Officials

The prosecution has accused Esformes of bribing doctors and inspection officials for the sole sake of increasing profits. First, Esformes bribed doctors to send patients to his nursing homes, using fraudulent referrals to claim patients needed services that were unnecessary. Then, when inspectors would review his patients, he would bribe them too.

Health care executives who exploit patients through medically unnecessary services and conspire to obstruct justice in order to boost their own profits—as alleged in this case—have no place in our health care system. Such actions only strengthen our resolve to protect patients and the U.S. taxpayers. — FBI Special Agent in Charge

Young and her team claim that Esformes received $450 million in fraudulent Medicare and Medicaid services, as a result of bribes. Esformes funneled $38 million of those funds to himself through a complex network of 256 bank accounts.

Esformes is also accused of receiving kickbacks from other health care facilities when we would fraudulently refer his patients to their centers. These centers would then fraudulently bill Medicare and Medicaid for unnecessary services as well.

Largest Medicare and Medicaid Fraud in History

Esformes case is a landmark trial, as it’s the largest health care scheme ever to be prosecuted by the government. It raises awareness of medical fraud and is a potential wake-up call for health care providers across the country.

Medicare and Medicaid fraud are far too common in the United States. Seemingly legitimate health care providers will knowingly bill the wrong medical codes for services that either weren’t performed or didn’t need to be performed.

Back in January 2016, America’s largest contract therapy provider for skilled nursing facilities was forced to return $125 Million in Medicare funds that were obtained through fraud, as part of a settlement. The four nursing homes that participated in the scheme also settled, paying a combined total of $8 million.

In 2011, eight nurses pled guilty to $18.7 million in Medicare fraud after their company billed prescriptions, therapy, and services that were medically unnecessary or never provided. Each of the nurses served prison time and were ordered to pay restitution. Daisy Santos, the nurse with the most severe punishment, was sentenced to 30 months in prison and $699,000 in restitution.

These cases are just a couple of examples of how fraudulent health care networks come with a lofty price tag at the expense of taxpayers and the government budget.

Nursing Home Medicare Fraud

Medicare fraud is abuse. It wastes patients’ time with unnecessary medical procedures, diminishes their quality of life and potentially limits their access to medical services when they are legitimately needed in the future. Health care providers who are willing to compromise the insurance system for their gain are abusive criminals.

A few examples of nursing home Medicare fraud include:

  • Billing Medicare for services that weren’t performed or were medically unnecessary but still performed
  • Manipulating therapy and treatment cycles to maximize billing
  • Billing Medicare for services that were more expensive or complicated than necessary
  • Unbundling services that are otherwise covered under a single, less expensive code
  • Inflating the reported amount of time spent with patients for services billed hourly

People bring their loved ones to nursing homes to ensure they receive better care than they would receive in their own homes. These fraudulent schemes do the opposite, exploiting vulnerable Americans so greedy businesspeople can line their pockets. Administrators and health care professionals who fraudulently bill Medicare to increase their profits need to be brought to justice.

If you suspect a health care facility or administrator is committing nursing home fraud or harming your loved one, it’s time to act. Contact Nursing Home Abuse Justice for a free legal case review.

References:

  1. Law 360, “Nursing Home Mogul Churned PAtients For Profit, Jury Told,” Retrieved from https://www.law360.com/articles/1070514/nursing-home-mogul-churned-patients-for-profit-jury-told Accessed on March 16, 2019.
  2. Miami Herald, “Miami Beach healthcare mogul ‘sold his own patients like cattle,’ jurors are told” Retrieved from https://www.miamiherald.com/news/local/community/miami-dade/miami-beach/article226121650.html Accessed on March 16, 2019.
  3. Miami Herald, “Once among the ‘1 percent,’ executive faces $1 billion Medicare fraud trial,” Retrieved fromhttps://www.miamiherald.com/news/local/article225176275.html Accessed on March 16, 2019.
  4. U.S. Department of Justice, “Three Individuals Charged in $1 Billion Medicare Fraud and Money Laundering Scheme,” Retrieved fromhttps://www.justice.gov/opa/pr/three-individuals-charged-1-billion-medicare-fraud-and-money-laundering-scheme Accessed on March 16, 2019.
  5. eHealth Medicare, “Avoid and Report Medicare Fraud and Abuse,” Retrieved fromhttps://www.ehealthmedicare.com/medicare-administration-articles/avoid-report-medicare-fraud-abuse/ Accessed on March 16, 2019.
  6. Centers for Medicare & Medicare Services, “Medicare Fraud & Abuse: Prevention, Detection, And Reporting,” Retrieved fromhttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/fraud_and_abuse.pdf Accessed on March 16, 2019.
  7. AANAC, “Blowing the Whistle: Uncovering Fraud in Skilled Nursing Facilities,” Retrieved fromhttps://www.aanac.org/Information/LTC-Leader-Newsletter/post/blowing-the-whistle-uncovering-fraud-in-skilled-nursing-facilities/2016-03-21 Accessed on March 16, 2019.
  8. Health Leaders Media, “8 Nurses Heading to Prison For Medicare Fraud,” Retrieved fromhttps://www.healthleadersmedia.com/nursing/8-nurses-heading-prison-medicare-fraud Accessed on March 16, 2019.