DoJ busts largest Medicare fraud in history

Using "data driven" law enforcement techniques, the Department of Justice has busted the largest Medicare fraud case in history.

More than a billion dollars in fraudulent Medicare claims over a decade were filed by a Miami-based health care provider. 

Washington Times:

Philip Esformes, 47, was arrested Friday by federal law enforcement officials at his Miami home. The owner of more than 30 nursing and assisted living facilities is charged with conspiracy, obstruction, money laundering and health care fraud involving numerous Miami-based health care providers.

“This is the largest single criminal health care fraud case ever brought against individuals by the Department of Justice, and this is further evidence of how successful data-driven law enforcement has been as a tool in the ongoing fight against health care fraud,” Assistant Attorney General Caldwell said in a statement.

Mr. Esformes‘ alleged fraud took place over more than a decade. The complex scheme required unqualified patients to join his Esformes Network and then receive unnecessary medical services.

Odette Barcha, 49, and Arnaldo Carmouze, 56, were also arrested and charged with obstructing justice as co-conspirators.

The government said the trio also sought kickbacks from health agencies and pharmacies.

"The magnitude of alleged false claims in this scheme is staggering and outrageous, even by South Florida health care fraud standards,” U.S. Attorney Wifredo Ferrer said. “This case illustrates once again that Medicare fraud has infected every aspect of the health care system.”

Michael Pasano and Marissel Descalzo, Mr. Esformes‘ attorneys, issued a statement refuting the government’s claims.

Mr. Esformes is a respected and well regarded businessman. He is devoted to his family and his religion. The government allegations appear to come from people who were caught breaking the law and are now hoping to gain reduced sentences,” the two said, the Miami Herald reported.

Rather than celebrating, DoJ should be alarmed. The Government Accountability Office believes that more than 10% of Medicare payments go to ineligible recipients. Most of that is fraud. The point being, the problem may be far larger than DoJ or the GAO believes.

One billion dollars is a huge amount of money. This isn't a government billion. This is a real life billion - one thousand million. The fact that the criminals got away with it for 10 years is equally troubling.

Better oversight is desperately needed. At least, it will make it harder to defraud the taxpayer.

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