Longform

Rx for Plunder

Page 5 of 9

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."

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Deirdra Funcheon