Rx for Plunder

On a crisp February morning in 2003, Dr. Evan Zimmer, dressed in jeans and a Hawaiian shirt, rolled up to work at the Oakland Community Health Center in Fort Lauderdale.

"I see this guy in Dockers hanging around the back door," Zimmer recalls. The man seemed to be guarding the place. Instantly, Zimmer sensed something wrong. "It was like getting a certified letter."

The man brusquely put his hand on the doctor's shoulder and escorted him inside — where a slew of FBI agents, pistols clipped to their belts, were dismantling computers and stashing files in boxes. They were seizing the health center's financial and medical records.

Zimmer's colleagues were nowhere in sight. He was shuffled into a small backroom. "It was very intimidating," he says. "I figured I was just a dead duck."

FBI agent Catherine Nazworth greeted the doctor with all the warmth of a hungry drill sergeant. Long, jet-black hair did nothing to soften her look. She stared Zimmer down. "This is your only chance to come clean," the psychiatrist remembers her saying.

His pulse racing, his brain in shock, Zimmer prepared to confess every mistake he'd ever made, starting from kindergarten.

There was little doubt about it: At the Oakland Community Health Center, laws had been broken. In seven years of operation, the program had scooped up $9.8 million in federal Medicare funds, ostensibly to provide outpatient care for mental health patients. Federal agents found that Oakland staff had routinely hyped results and submitted spurious reports. They also found that Oakland was, from top to bottom, a nest of nepotism, with family members not only directing the program but also providing contractor services.

Since Medicare was created in 1965 for the elderly and disabled, millions have benefited. A vast $400-billion-a-year system now providing health care to about 43 million beneficiaries, Medicare has also become a target for an array of rip-off artists, from medical equipment suppliers who don't deliver to "Medicare mills" that charge the government for treating nonexistent patients.

Oakland was a small-time player in the Medicare game. But the prosecution of directors and staff members by federal authorities offered a rare inside glimpse of how seemingly nice people can get swept up into a system in which money comes so easily that it's hard to say no.

Medicare fraud — which, according to those familiar with the system, is remarkably easy to commit — has come to cost taxpayers billions each year. But investigators and prosecutors say they are catching on, going after big and small abusers. These days, the feds are in serious chase mode, especially in Florida, where Medicare pumps out billions in benefits.

According to friends and family, Oakland Community Health Center's director, Bernard Graves, was a handsome man who grew up in Key West and moved to Broward County to work as a probation officer. Glasses perched on his nose, his hair pulled back into a ponytail, he exuded control and confidence. His wife, Althea Richards, with her smarts and strong will, had caught Bernard's eye while she was still a student at Piper High School. Both Bernard and Althea seemed to have an eye for opportunity.

By the mid-1990s, the couple had realized that health care wasn't a bad way to make a living.

It's expensive to stick a person in a mental hospital. To reduce hospital costs, Medicare established the Partial Hospitalization Program to serve patients who suffer from acute illnesses but don't quite need 24-hour care at a hospital. People with profound mental health conditions could get intensive treatment at a Community Mental Health Center (CMHC) during the day and still return home at night.

As the indictment that would later charge the Graveses with 43 counts of criminal wrongdoing notes, Medicare would foot the bill for CMHCs only under certain conditions: Patients must need treatment due to "a mental disorder that severely interfered with multiple areas of daily life." However, they needed to still have "the mental and physical capacity to have actively participated in all phases of the program." The treatment needed to be "vigorous and proactive as opposed to passive and custodial," and Medicare required "a reasonable expectation of improvement of the patient's disorder" as a result of the program. A doctor was required to certify the need for the treatment, and the CMHC was expected to maintain detailed records on site.

Opening a CMHC must have looked like a golden idea to Bernard and Althea. There were no educational requirements. Doctors and therapists could simply be hired. Once the paperwork was approved and an inspector OK'd the facility, voilà! — they'd be issued a provider number and could start billing Medicare.

Bernard would become the administrator of the Oakland Community Health Center and Althea the assistant administrator. They would bring on Althea's mother, Yvonne Howell, a registered nurse who ran four nursing homes, as clinical director. According to those familiar with the case, Bernard did not disclose his 1995 felony conviction for marijuana possession or his arrest for driving on a suspended license the following year.

Medicare did have a little rule about "related party" transactions. If, say, a CMHC wanted to do business with a family member, it could — but it would get reimbursed for costs only. It wouldn't be allowed to tack on a profit. Any "related party" relationships must be disclosed.

This technicality did not appear to be an obstacle at Oakland. Bernard Graves and Althea Richards might have lived together since 1990, but they weren't married (until 2001). Yvonne was licensed as a nurse under her maiden name, Yvonne Howell.

In February 1996, the Oakland Community Health Center opened for business on Andrews Avenue (it later moved to Sunrise Boulevard). At the front desk sat a pretty young girl named Mashama Brannigan, fresh out of technical school, where she'd been trained in medical transcription. Althea's high school friend, a woman named Tabatha Harrell, worked as an administrative assistant and also spent much of her time at another business — Basic Home Care Medical Supplies, owned by Althea and her brother Dwight Richards.

On the clinical side of the operation, Oakland hired qualified staff: A stream of licensed clinical social workers (LCSWs) was controlled by the lead therapist, a ponytailed, Ivy League-educated redhead named Neil Leder. For a man with a magic signature who could admit patients and sign prescriptions, Oakland contracted with a friendly psychiatrist: Dr. Zimmer. Yvonne Howell oversaw the day-to-day operations of the clinical team.

According to testimony that was later presented at trial, patients were carted in from Yvonne's nursing homes as well as from other assisted living facilities (or ALFs). For the ALF owners, it was a dream situation: Patients — as few as eight or as many as 40, depending upon the year and season — would be scooped up in the morning and brought to Oakland, where they were fed hot meals and received treatment that included counseling sessions, HIV education, and anger-management classes. They would be dropped back home in the afternoon. This would cost the ALFs not a dime — Medicare picked up the bill.

Intake forms signed by Yvonne Howell show that many of Oakland's patients survived each month on a single Social Security check. An average patient's total income: $650. Expenses: $600 for the nursing home and $50 for medicine. Patients suffered from a variety of mental ills: schizophrenia, bipolar disorder, depression.

Zimmer made a living as something of a freelance doctor, working part-time at several CMHCs. He would drop by Oakland, he says, for about two hours twice a week. For this, Brannigan would later tell the FBI, he was paid $2,000 a week. Upon his arrival, he'd pop in through a back door and check in with Yvonne. "Patients would have already been triaged by a licensed clinical social worker or Yvonne, who was a psychiatric nurse," Zimmer says. "If they met the criteria for admission, they would be met by me." He would see patients and dictate notes on tape. Part of his job, he says, was to move paperwork. He'd sign things such as progress notes and psychological evaluations. In one instance, he left a stack of completed papers with a note dashed on a prescription pad: "I'm caught up! Love, Evan." If asked to, he admits, he would sign blank forms.

For the most part, this arrangement worked fine — except that in order to get money from Medicare, patient files needed to be a certain way. What if Zimmer's diagnosis didn't match what Medicare paid?

Brannigan, who spoke repeatedly to the FBI, said that in the early days, she would type Zimmer's notes precisely — but when Yvonne noticed something that might block Medicare payments, she'd instruct Brannigan to redo the paperwork, adding or omitting key points. For example, Brannigan said, if Zimmer dictated that a patient had "severe dementia," Howell would instruct Brannigan to change it to "mild" or else simply delete it.

Sherri Issa, a social worker who worked at Oakland, told investigators a similar story. If a patient came in clean and tidy, she said, therapists were instructed to note that he showed up disheveled but became tidy by the end of his time at Oakland. Other therapists told similar tales: If someone had dementia, they were to note "altered thoughts" instead. Eventually, the staff knew what was expected.

If Zimmer was not around when bills needed to go out, Harrell later testified, she would simply forge his signature. If a therapist quit before signing her group notes, one of the office staff would cut out her signature from old paperwork and photocopy it onto a new document. What was the difference?

Some people in the medical field say Medicare is a Kafkaesque employer, a huge bureaucracy with no human face and often no clear answers. Bernard Graves' lawyer, Lilly Sanchez, says: "Medicare regulations can be extremely confusing. You can call the hotline and things aren't clearly explained — whether something's a proper cost or not, whether you can make a profit or not." Consulting businesses have sprung up to advise providers on how to tailor their billing so that most claims get paid. For providers dependent upon Medicare for income, the cherished goal is to stave off audits and keep the money flowing.

To get paid, Oakland would pass information on to its biller, Michael Evans. He would submit the required information, like diagnosis codes and procedure codes, to the "fiscal intermediary" — a company called First Coast Service Options. (Medicare doesn't accept claims and pay bills directly; it contracts with intermediaries like First Coast to handle such tasks.)

Under normal circumstances, money is moved quickly and bills are paid automatically. It's in the intermediary's interest to keep things going smoothly — and maintain its lucrative contract with Medicare. However, should the intermediary notice something funny — a spike in billing for a certain item, for example, or extraordinarily high costs — the intermediary conducts an audit, the Medicare money gets put on hold, and the whole machine powers down.

There were indeed times that Oakland was put on review. During these periods, Medicare funds would be shut off for months while administrators scrambled to get papers in order. Therapists were laid off, and Zimmer would quit. Harrell would then work solely at Basic Medical Supply, Althea's other company, and Leder would sell items on eBay to get by. When the facility was cleared, the machine powered back up, and staff members got re-hired.

Office workers would later testify that Althea called her own mother "Yvonne" and that Yvonne was not allowed in Althea's office. Multiple staff members told the FBI that they suspected the three administrators were related but that "family relationships at Oakland were secret."

When times were flush, various witnesses said, Althea and Bernard bought sports memorabilia at auctions. They took a furniture-buying trip to North Carolina. They started work on their nearly $2 million mansion in Davie. In 1996, Oakland's first year of operation, Bernard Graves made $99,784, Althea $40,707. By 1998, the salaries had jumped: Bernard was making $132,392, Althea $115,969. Zimmer says Bernard traded in his Ford Explorer for a black Mercedes with chrome rims. He joked that Bernard wore "so much gold he was going to get his ass arrested." With his nice clothes, his cool demeanor, and his hair in a braid, the administrator came off to some as a player. He bore a striking resemblance to the central character in the movie Pootie Tang.

When things were going well, they were going well for everyone. Leder lived comfortably on his $60,000-a-year salary, Harrell, the assistant, was paid $18,648 — and $73,000 two years later. Various reports put Yvonne Howell's earnings between $60,000 and $150,000.

And so it went, until a couple of anonymous tips came along.

Forging signatures and fudging paperwork — that's one way to defraud Medicare. There are a thousand variations on the theme.

Cesar Arias drives through Miami, gesturing toward glittery condominiums transforming the skyline. "Did you ever notice there's never a recession here?" he asks. In his eyes, Medicare money powers the entire South Florida economy. "It's bigger than tourism." Arias declines to give a hard number, but published estimates vary from $2 billion to $33 billion in suspected Medicare fraud each year.

Arias, a registered pharmacist turned private investigator (his company, Stonecold Investigations, works for pharmaceutical companies to investigate potential fraud), contends that a Medicare provider number is the "golden ticket" to riches. High school dropouts can get one. There's no need for medical experience or even a college degree. No criminal-background checks are performed (though applicants are required to disclose criminal histories when they apply). There's no bonding requirement. Applicants don't even have to speak English.

These days, the biggest scams are happening through durable medical equipment providers, authorities say. Criminals with provider numbers charge Medicare for wheelchairs, prosthetic arms, and oxygen concentrators that they never actually buy or deliver to patients. Another popular scheme is HIV infusion clinics: Providers bill Medicare for the cost of doling out expensive medicines and drips — but what they really give patients is a cheap concoction of vitamins.

Don't even get Arias started on counterfeit medicine — how wholesalers slap fake labels on boxes of fake pharmaceuticals and — you guessed it — bill Medicare. The profit margin there, Arias says, "is better than printing money." He points to the case of Julio Cruz, who pleaded guilty to conspiring to sell $12.8 million worth of fake Lipitor, a cholesterol-reducing medication.

Arias says doctors, nurses, and elderly Medicare recipients either don't notice that their good names and Medicare numbers are being used to run the scam — or else they're getting kickbacks for participating. In the rare instance that a Medicare investigator actually comes knocking, the criminals have already fled — stopping at the check-cashing store on their way out of town.

Committing fraud is simple, says one prosecutor in the Department of Justice, because "100 percent of Medicare claims are auto-adjudicated. No human looks at it." In the old days, Medicare paperwork was burdensome. But now, claims are put through a computerized system and automatically paid — direct-deposited into providers' accounts within 16 days. Payments are halted only if the software detects something wrong, if, say, a code for gynecological procedure is matched to a male Medicare patient. In contrast, the source explains, a private insurance company might automatically pay 60 percent of its claims and deny — or at least look into — the other 40 percent.

"Medicare would be better off just putting million-dollar bundles of cash in bags and handing them out," the prosecutor says.

According to Arias, Medicare "keeps on sending the money, and after a while they go, 'Oh shoot — better go investigate!' " Insiders call this "pay and chase." Good luck getting the money back. The Center for Medicare and Medicaid Services, an arm of the Department of Health and Human Services, has only about a dozen investigators in South Florida.

The slack on Medicare's end makes plenty of work for the U.S. Attorney's Office. "Federal prosecutors are so overwhelmed," Arias says, "they just pick the juiciest cases to prosecute." It can take years to seize evidence, pore through medical records, and build a solid case. Arias guesses that anyone bilking less than a million dollars a year doesn't even get sniffed at. Even when prosecutors do nail big-time crooks, he says, "It's like bailing out a boat with a fork."

According to Gabriel Imperato, a Fort Lauderdale attorney specializing in medical fraud, it wasn't until the late '70s that the government really noticed abuses of the Medicare system. By the early 1990s, the problem was out of control. In recent years, though, whistleblowers have started taking advantage of the False Claims Act; cooperators flip on their criminal buddies and get a cut of the proceeds when misused government funds are recovered. In what's called a qui tam action, a person who sees fraud being committed can file suit as the plaintiff, or "relator," on behalf of the government. If fraudulent monies are found, he or she stands to get a piece of the pie.

"Now, whistleblowing is driving the issue," Imperato says. "Everyone's ratting each other out. It's driving tons of insider info into the Department of Justice."

In 1996, the Health Care Fraud and Abuse Control Program was established to go after health care fraud. By the end of 2005, the program — a joint effort between HHS and the Attorney General's Office — had recovered $8.85 billion and deposited it in the Medicare Trust Fund.

Arias points out that South Florida, with its wealth of elderly patients, is the epicenter of health care fraud. Including federal health operatives, the FBI, and state agencies, he estimates there are 90 agents working to combat the problem, plus a staff of prosecutors in the U.S. Attorney's Office. In 2000, authorities opened a giant facility in Miramar where investigators from various agencies could work together to root out health care scams.

R. Alexander Acosta is the U.S. attorney for the Southern District of Florida. Sitting in his eighth-floor conference room in downtown Miami, Acosta speaks freely about his "three-pronged" mission to go after Medicare scammers. "In late 2005," he explains, "we took a look at what was going on in South Florida and the amount of health care fraud. We said, 'Hey, this is our money! We have to go after it more aggressively.' "

In 2006, Acosta says, prosecutions went up 30 percent. His office indicted more than 50 cases and charged $138 million in fraud. By July 2007, they'd indicted another 70 cases and charged $290 million. That's not even counting an August indictment alleging $170 million in one fraud case alone.

In February, the Department of Justice partnered with HHS, the FBI, and local law enforcement agencies to create a fast-acting superpower: the Medicare Fraud Strike Force. Acosta wants to fight the impression that his office is pursuing only "the worst of the worst. Like, if you stay small, you're going to go under the federal radar." The Strike Force allows enforcers to execute warrants and seize files quickly. So far, it has had success finding what Acosta calls "small cases — two-, three-, five-million-dollar cases."

But the force is just one part of his approach. "I understand the desire to be sexy," he says, "but I don't want to give the impression the Strike Force is where the action is at." He also uses long-term criminal investigations to "go after the biggest and baddest."

Acosta's "third prong" of weaponry is civil cases, wherein the main goal is to recover money, not necessarily put people behind bars. Such cases are helpful when criminals have fled but left money behind in bank accounts. In one investigation, Acosta's office identified 66 suspicious accounts and recovered $111 million from 23 of them.

Why doesn't Medicare prevent the whole cat-and-mouse game by simply tightening its regulations in the first place?

Because, Cesar Arias scoffs, "It's not their money!"

Cynicism aside, the real answer is more complex, those familiar with the system say. Medicare, being a huge bureaucracy, moves slowly. Any little change can affect millions of patients, billers, and providers. Should the agency dare introduce any measure that could be construed as stopping seniors from getting care or doctors from getting paid, it can expect a massive backlash. For example, "It took years for Medicare to stop paying for compounded aerosols," Arias says, referring to another hot scam in which shady providers bill Medicare for expensive, custom-made inhalers — an item that had high profit margins — when most respiratory problems can be treated with cheaper, commercially available inhalers.

Acosta sees progress from Medicare administrators. Medicare recently started requiring equipment suppliers to reapply for their provider numbers and launched random, unannounced inspections. His office, however, is "not in the business of second-guessing best medical practices. We're lawyers, not doctors. We're in the business of stopping fraud."

Bernard, Althea, and Yvonne may not have realized how eagerly the prosecution would be coming after them.

In December 2000, a curious e-mail was sent to Medicare's Office of the Inspector General. It was from therapist Sherri Issa. After working at the Oakland Community Health Center for several months, she had noticed that "patients admitted into this program either have no history of mental illness or suffer primarily from organic mental conditions which would [disqualify them] from this program."

She did not mention that she'd filed a suit as the relator in a qui tam action against Cleveland Clinic the year before.

It's unclear if Issa was eyeing the possibility of getting more money by whistleblowing or if any investigations were launched as a result of her complaint. But by December 2001, Washti Bajnath, First Coast Service Options' auditor, had his own suspicions about Oakland. Bajnath, a native of Trinidad, had a nose for fraud and a gift for math, making him perfectly suited for forensic accounting. Judging by his comments in court documents, few things pleased him more than to follow a money trail straight back to thieves and pin them in a corner with data.

Bajnath noticed that Bernard, Althea, and Yvonne had been sharing addresses for years. He noticed that the man they were paying to drive the van and clean the office was Yvonne's brother, Andrew Howell. The company they were paying for staffing? Owned by Stenneth Robinson, Yvonne's son. Robinson also leased Oakland its office space ($1,908 per month) and its furniture ($2,351 monthly). Various cousins, wives, and in-laws came and went as nurses or assistants at Oakland. None of this had been disclosed under the "related party" rule.

Bajnath also saw that Althea claimed to have master's and bachelor's degrees from some place called Columbia State University; Bernard had supposedly earned a Ph.D there.

Althea had gotten hers for $2,995 and Bernard his for $3,400. Not only had Bernard and Althea claimed higher salaries because of these credentials but they sought reimbursement for their education on Medicare cost reports. CSU was a diploma mill shut down by the FBI in 1998.

Furthermore, Bajnath noticed that Oakland never billed patients for coinsurance. CMHCs were supposed to bill Medicare for 80 percent of a patient's care and charge the patient for the other 20 percent, like a copayment. If a patient couldn't afford it, Medicare would pick up the costs. But Oakland didn't even bother to bill until being investigated.

Bajnath also found that Yvonne charged Medicare $60 an hour for duties Harrell should have performed for a sixth of the price. Yvonne got paid as a clinical director and then paid again as a consultant to review the same files she had prepared.

Had Bajnath not been scrutinizing Oakland already, an anonymous letter would certainly have got him started. On May 1, 2002, he received a note that read: "I would like this matter to remain in strict confidence. I am an employee of Oakland Community Health Center. I am writing to report the illegal activities of this center. I am very frustrated and tired of the unprofessionalism as well as the unethical practices of the administrators of this company."

Lawyers in this case later determined that the letter came from Mashama Brannigan. But it could have been written by anyone working at the Oakland center. In January 2002, Harrell had been accused of stealing from Basic Home Care; in February, she was dismissed, she would tell the FBI, "like the common field slave." Multiple therapists had left voluntarily; one got fired for dressing sloppily, another for taking paperwork home. In April, the administrators had security cameras installed.

Somewhere along the way, the profitable little business had become a hive of bitterness. As a family friend would later observe, "sweet turns sour."

The FBI raided Oakland's offices in February 2003, but the company's principals roamed free for three years while investigators sifted through records in Miramar and conducted dozens of interviews — at federal offices, at Dunkin' Donuts, at Denny's.

Dr. Zimmer says he never again set foot in Oakland Community Health Center. With no patient files to work with, a plummeting reputation, and no more Medicare money, the facility went out of business.

In the course of its investigation, the FBI — mainly, the raven-haired Agent Nazworth — only unearthed more dirt. Documents indicated that sometime after Oakland opened, Althea had started another business called Guiding Light. When it failed to qualify for a Medicare provider number, she put its bills through under Oakland. Canceled checks and testimony from employees showed that she and Bernard took bills for improvements made to their home and put them through to Medicare as though work had been done at Oakland.

To strengthen its case, the government used a powerful technique: offering various degrees of immunity to some co­operators in exchange for information or testimony against defendants it deemed more culpable.

Once Michael Evans, the biller, was offered such a deal, he dropped a bomb: He told investigators that from the earliest days he worked with Oakland, he'd given kickbacks to the facility. Terminally ill and desperate for money, he would have lost the contract otherwise, he explained. He claimed that Bernard once threatened him and that his motorcycle was mysteriously sabotaged. So Evans gave Oakland 50 percent of what he'd made from Medicare — ranging from $51,000 to $116,00 annually over the years.

The feds also claimed that Oakland was offering kickbacks to clients. Emmins Henry, owner of the Shalom Manor assisted living facility, said she received rewards from Oakland: Yvonne would give her boxes of diapers and supplies for the patients and provide turkeys at Christmas. On at least one occasion, she told the FBI, she got an envelope that contained $50 to $100 in cash for the patients.

Allegations surfaced that, on at least one occasion, Neil Leder billed for therapy when in fact he had turned on a video of The Sound of Music and left the room. Confronted by the FBI and federal prosecutors, Leder answered questions only grudgingly. Had he piped up a little bit sooner, he too might have been granted immunity from prosecution. His second meeting with the FBI, according to an agent's report, "concluded early because of Leder's evasiveness." Prosecutor Robert Nicholson advised him to seek legal counsel.

Armed with such overwhelming allegations, then-U.S. Attorney Nicholson had no qualms about charging Althea, Bernard, Yvonne, and Leder with a whopping 43 criminal counts.

Nicholson had little sympathy for the accused. Of the mansion that Bernard and Althea were building, he said, "Donald Trump would blush at the opulence of this house." Oakland had been paid nearly $10 million by Medicare over the years — but that's not even counting claims that got denied. They'd tried to get $28 million. "Fraud was pervasive in every aspect of their business activities," Nicholson says.

Was there any evidence that Leder or Yvonne profited to the same degree as Bernard and Althea? "No. But they drew salaries, made false statements, and intentionally omitted facts."

The family's actions were in line with the massive, blatant fraud Nicholson sees all the time. "A Medicare provider number is a license to steal."

Bernard and Althea chose to take plea deals. Of the 43 counts on the indictment, all were dropped except one: conspiracy to make false documents relating to health care matters.

During his sentencing hearing in July, Bernard Graves said to federal Judge William Dimitrouleas, "I stand in responsibility." He likened himself to a general in charge of soldiers on a battlefield — soldiers, that is, who failed to follow his instructions. Bernard wondered aloud why no doctor was going to jail.

Bernard was ordered to serve five years in prison. Dimitrouleas flat-out stated he would have piled on more time had the attorneys "not limited my jurisdiction to just one count." Two U.S. marshals stood up and snapped Bernard's wrists into handcuffs. He looked even more like Pootie Tang as the officers removed his belt; his power seemed to fade as they led him away. Friends and family, including Bernard's pastor, watched helplessly. Althea ran from the courtroom.

At her own sentencing several weeks later, Althea faced the judge. She wore a maroon outfit with a flower print. Her hair was pulled into a bun just as tight as her unsmiling mouth.

Several people watched from the benches, sniffling for her and making overtures to Lord Jesus. Althea's pastor spoke on her behalf, saying that she and Bernard had enrolled in the Institute of Theology by Extension, a five-year program that would allow them to get pastoral licenses. The pastor told the judge he'd pray for him.

That was nice, but Althea got four years and three months anyway.

Taxpayers had footed the bill for the Graveses' lush lifestyle and mansion. Taxpayers had shouldered the costs of their prosecution. Now, taxpayers would give the couple shelter and food — in the form of concrete walls and baloney sandwiches.

The couple had amassed a small fortune in real estate — but most properties would be foreclosed upon as part of the $5 million in restitution they were each ordered to pay. In plea agreements, the couple's defense lawyers specified that the defendants would be allowed to keep a two-story house, worth $597,350, in a gated neighborhood in Stuart — that is, if relatives pay the mortgage on it. (The couple sold the mansion.)

Neil Leder decided to cooperate with authorities — eventually. He took a plea deal and is serving 17 months in prison. According to Leder's attorney, his wife, a librarian, is trying to pay her mortgage alone, and Leder's elderly mother is kicking in to help.

Tabatha Harrell went into business with her sister selling diabetes supplies.

Mashama Brannigan found work in the funeral business.

Michael Evans still works as a biller.

U.S. Attorney Nicholson has since gone into private practice as a defense attorney.

No one could say what had happened to the patients who'd been seen at Oakland. A Medicare spokeswoman gave no specifics, saying only that the agency "always moves to protect Medicare beneficiaries when [it] hears or is notified by another agency that a provider is being closed."

When Oakland shut down, Yvonne Howell liquidated her interest in two of her nursing homes but went back to work at one. As she went about the business of dressing wounds and changing diapers, she clung to her declaration of innocence. She decided to take her chances and go to trial.

Evan Zimmer, the Oakland program's affable psychiatrist, benefited from the government's immunity deal, and he was not charged with any wrongdoing. These days, he works in the pain management field.

He didn't testify against Yvonne at trial. Sources familiar with the case said no lawyer would put Zimmer on the stand because opposing counsel would try to discredit him by bringing up a well-known incident from his past. In 1984, Zimmer fell asleep at the wheel of his convertible and crashed into the water. When police arrived, he was swimming to shore with a baggie in his mouth. It contained about 500 prescription pills, including Valium, Vicodin, and Xanax, that he had rescued from his sinking car.

These days, Zimmer laughs off the incident. "I learned you can't take a car waterskiing!" he says. Zimmer went into detox and now proudly states that he became the first doctor in Florida to lose his license and get it reinstated. He changed his specialty to psychiatry and specialized in addiction therapy, putting to good use his ability to empathize with recovering addicts.

Zimmer acknowledges his share of personal problems. Doctors, he notes, are not infallible creatures who breathe some rarefied air. When he came to Oakland Community Health Center, he was a dude in need of a job.

Still, he feels that every patient treated at Oakland deserved to be there. "My job at a PHP was to prevent further deterioration," he says. Despite all of the work that had been put into falsifying documents to make patients look as if they were improving, Medicare regulations do indeed state that PHPs are "reasonably expected to improve or maintain" the individual's condition to prevent relapse or hospitalization. Though with stays at Oakland limited to 30 or 45 days, he says, the program was often forced to discharge patients "before we could see if the meds were working."

He concedes that he signed freely on psychiatric evaluations, progress notes, and charts. He adds, though, that in today's health care environment, it's necessary to move paperwork expediently. Health care is based on trust, he says. "When a nurse tells you that a patient has a fever, you don't ask to see a picture of the thermometer with today's newspaper in the background."

Zimmer says he has no problem with rules that allow owners of CMHCs to operate without any medical education requirements. "What does admin have to do with clinical?" he says. Zimmer's the kind of guy who has "trouble counting change, but I can do calculus." He always stayed on the medical side — "far away from the cash register."

But when he heard what happened to Yvonne, he felt heartbroken. "She's good people."

Yvonne Howell's lawyer, Allan Kaiser, tall, lean and mustached, waved his hands and argued passionately in front of the jury.

Kaiser acknowledged that some documents from Oakland were back-dated — but Yvonne was just making sure paperwork was in order! Maybe a few patients were not quite qualified for PHP treatment — so why did the doctor admit them? Yeah, Yvonne gave boxes of diapers to ALF owners — she's a nice lady! She had no authority to sign checks and no control over bank accounts. She did not make an exorbitant profit. She owned a few scrappy properties, he pointed out, but no mansion.

But witness after witness took the stand with at least one point to make against Yvonne Howell. Prosecutors introduced more than a thousand exhibits. Of 168 patient files, they pointed out something fishy in 167.

Watching a long, complicated case about health care fraud was no fun for the jury. "If you're going to do jury duty," said one of two jurors who spoke about the case on the condition that their names not be used, "why do we have to have the most boring people on the planet? One morning on my way into court, I was making a left at a traffic light and [prosecutor Nicholson] was crossing the street. I thought, 'Should I accelerate?' He's so boring! I don't want to hear him today!"

The juror described Nicholson's fellow prosecutor on the case, Roger Stefin, as "very boring but not as boring as the other one." Asked to justify his boringness, Stefin said wryly, "Sometimes we have to bore them into a conviction."

Once her three codefendants had taken plea deals, Yvonne Howell stood alone, charged with 23 counts from the original 43-count indictment. After a three-week trial and three days of deliberations in May, a jury found her guilty on ten of those counts. The allegations involving the alteration of documents — she was clearly guilty of those, the juror said. "I don't get the feeling she did it maliciously, though. Nurses say what they say in order to get patients treated."

But conspiracy to pay kickbacks and launder money? Those were a technicality, the juror explained. Because of the way the jury instructions were worded, they felt they had to find Yvonne guilty on those two counts. Upon being dismissed, the juror ran from the courtroom to the parking garage, where, racked with stress for determining the fate of a fellow human being, she promptly threw up.

Three months later, Yvonne was back in court, sitting under fluorescent lights in her prison jumpsuit, her hands cuffed, her hair cropped short. Only three people came to her sentencing.

Kaiser argued that Yvonne should get less time than Bernard and Althea, the two most culpable defendants. Otherwise, "my client is being punished for exercising her constitutional right to go to trial!" he cried. "What did my client get out of all this?" Like everyone else, he tried foisting the blame upon Zimmer.

"Frankly," prosecutor Stefin said, "in hindsight, Zimmer should have been charged."

It was Yvonne's turn to speak. "I am 60 years of age," she began. "I have spent my life taking care of the mentally ill and the aged people in society — the forgotten ones. I have spent long hours trying to get assistance for the poor and needy." She sniffled. "I sat here and listened to the testimony of Mashama Brannigan. At no time did she say that I was like a mother to her. I listened to Tabatha Harrell. At no time did she say that I gave her shelter when she was homeless with a 10-year-old daughter. I listened to Neil Leder. At no time did he say that I helped him when his car broke, to fill his radiator, or when he had no shoes."

Her voice started to break. "I have been like a Florence Nightingale or a Mother Teresa. And I am asking you for mercy."

Despite her supplication, Yvonne Howell was ordered to serve ten years and one month in prison and pay $9.8 million in restitution.

Kaiser was furious. Howell had not profited exorbitantly, he said, but her sentence was more than twice as long as Bernard's or Althea's. Only after Howell's sentencing did Kaiser learn from a New Times reporter that Sherri Issa had won half a million dollars in her qui tam action. Had he known that during trial, he may have been able to discredit Issa — "my most damning witness" — on the stand.

Two weeks ago, he filed a motion for a new trial.

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Deirdra Funcheon