Friday, August 12, 2011

Miami Woman is 10th Person Arrested for Her Role in Leading $27 Million Health Care Fraud Conspiracy

Wifredo A. Ferrer, United States Attorney for the Southern District of Florida; John V. Gillies, Special Agent in Charge, Federal Bureau of Investigation (FBI), Miami Field Office; and Christopher B. Dennis, Special Agent in Charge, U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG), Office of Investigations, announced today’s arrest of Elizabet Lombera, 39, of Miami Lakes, Florida. On August 4, 2011, a federal grand jury in Miami indicted Lombera with one count of conspiracy to commit health care fraud, in violation of Title 18, United States Code, Section 1349, six counts of health care fraud, in violation of Title 18, United States Code, Section 1347, and six counts of aggravated identity theft, in violation of Title 18, United States Code, Section 1028A, Case No. 11-20528-Cr-Seitz.

If convicted, the defendant faces a possible maximum statutory sentence of 10 years’ imprisonment on the conspiracy and the health care fraud counts. In addition, each count of aggravated identity theft carries a two-year mandatory minimum term of imprisonment to run consecutive to any other sentence.

According to the indictment, Lombera and her co-conspirators installed nominee presidents to hide her control of five durable medical equipment companies in Miami that submitted fraudulent claims to Medicare, including Mercy Medical Supply, Inc., JHH Group, Inc., La Numero 1 Farmacia Discount Corp., Yani’s Pharmacy, Inc., and El Perimetro Farmacia Discount Corp. Collectively, these five companies submitted approximately $27,383,328 in fraudulent claims to Medicare and received $12,438,952 in reimbursements. The indictment alleges that Lombera used the proceeds for personal gain, including paying for a trip to Japan.

Six of Lombera’s co-conspirators have already been sentenced for their roles in this conspiracy. Maykel Diaz Escalona, the nominee owner of Mercy Medical Supply, Inc., was sentenced to 37 months’ imprisonment inUnited States v. Maykel Diaz Escalona, Case No. 09-Cr-20084-Graham. Marcelino Avila, the nominee owner of JHH Group, was sentenced to 46 months’ imprisonment, in United States v. Marcelino Avila, Case No. 08-20730-Cr-Seitz. Douglas Reina, the nominee owner of Yani’s Pharmacy, was sentenced to 37 months’ imprisonment in United States v. Douglas Reina, Case No. 08-Cr-20330-Huck. Obel Martinez was sentenced to 36 months’ imprisonment for laundering approximately $620,000 of health care fraud proceeds in United States v. Obel Martinez, Case No. 10-Cr-20546-King. Emilio Bezanilla was sentenced to 30 months’ imprisonment for laundering approximately $195,000 in United States v. Emilio Bezanilla, Case No. 11-Cr-20096-Lenard. Finally, Edisnel Diaz Soler was sentenced to 27 months’ imprisonment for laundering approximately $580,000 of health care fraud proceeds in United States v. Edisnel Diaz Soler, Case No. 10-Cr-20876-Huck.

Four other individuals have been charged. Luis Fuentes, the nominee owner of El Perimetro, was charged in United States v. Luis Fuentes, Case No. 08-Cr-20199-Martinez, but remains a fugitive. Eliezer Lazo, Joel Martinez Hernandez, and Casimiro Martinez have been arrested and charged separately for their roles in laundering the proceeds of the health care fraud and are awaiting trial in United States v. Eliezer Lazo, Case No. 11-20447-Cr-Altonaga; United States v. Joel Martinez Hernandez, Case No. 11-20446-Cr-Moreno; and United States v. Casimiro Martinez, Case No. 11-Cr-20448-Jordan.

Mr. Ferrer commended the investigative efforts of the FBI and HHS-OIG. These case are being prosecuted by Assistant U.S. Attorney H. Ron Davidson and Trial Attorney O. Benton Curtis of the Criminal Division’s Fraud Section.

An indictment is only an accusation and a defendant is presumed innocent until and unless proven guilty beyond a reasonable doubt.

What is Single Payer

What is Single Payer?

Single-payer is a term used to describe a type of financing system. It refers to one entity acting as administrator, or “payer.” In the case of health care, a single-payer system would be setup such that one entity—a government run organization—would collect all health care fees, and pay out all health care costs. In the current US system, there are literally tens of thousands of different health care organizations—HMOs, billing agencies, etc. By having so many different payers of health care fees, there is an enormous amount of administrative waste generated in the system. (Just imagine how complex billing must be in a doctor’s office, when each insurance company requires a different form to be completed, has a different billing system, different billing contacts and phone numbers—it’s very confusing.) In a single-payer system, all hospitals, doctors, and other health care providers would bill one entity for their services. This alone reduces administrative waste greatly, and saves money, which can be used to provide care and insurance to those who currently don’t have it.

What is Single Audit?

Each year, the Federal Government provides over $400 billion in grants to State, local and tribal governments, colleges, universities and other non-profit organizations (non-Federal entities). The Single Audit Act of 1984 (with amendment in 1996) and OMB Circular A-133 ("Audits of State, Local Governments, and Non-Profit Organizations") provide audit requirements for ensuring that these funds are expended properly. All non-Federal entities that expend $500,000 or more of Federal awards in a year ($300,000 for fiscal year ending on or before December 30, 2003) are required to obtain an annual audit in accordance with the Single Audit Act Amendments of 1996 (pdf), OMB Circular A-133, the OMB Circular Compliance Supplement and Government Auditing Standards. A single audit is intended to provide a cost-effective audit for non-Federal entities in that one audit is conducted in lieu of multiple audits of individual programs. The Single Audit provides the Federal government with assurance that these recipients comply with such directives by having anindependent external source (the CPA) report on such compliance.

OMB Circular A-133 Compliance Supplement 2009