11th Circuit Upholds $70M in Miami Medicare Fraud Verdicts

The U.S. Court of Appeals for the Eleventh Circuit has upheld $71 million worth of Medicare fraud penalties in Miami.

The court shut down a list of unfair trial accusations and upheld prison and restitution sentences for a doctor and three therapists formerly with Health Care Solutions Network Inc. They were convicted of conspiracy to commit health care fraud.

The case was part of “an extensive Medicare fraud scheme” that spanned seven years, orchestrated by the company’s owner and facilitated by multiple employees, according to an opinion by Judge Charles Wilson released Wednesday.

Circuit Judge Robin Rosenbaum and District Judge Eduardo Robreno of the Eastern District of Pennsylvania, sitting by designation, joined in the ruling.

The decision upheld Judge Robert Scola Jr. of the Southern District of Florida in his handling of the trial and sentencing of Dr. Roger Rousseau, medical director for Health Care Solutions Network in Miami, and therapists Doris Crabtree, Liliana Marks and Angela Salalfia.

Health Care Solutions Network was a “partial hospitalization program” designed to provide intensive psychiatric therapy to patients with “serious and acutely symptomatic mental illnesses,” Wilson said. Such programs serve as a bridge between restrictive impatient care in a psychiatric hospital and routine outpatient care. Medicare standards require close supervision and extensive documentation. The length of stay must be justified, because anything more than three months indicates the treatment is ineffective or no longer appropriate.

The company violated the required safeguards and documentation practices, according to the opinion. “From intake to discharge, HCSN organized its business around procuring, retaining, and readmitting patients to maximize billing potential, without respect to patients’ health needs. It then ensured patient files complied with Medicare coverage requirements by editing intake information, fabricating treatment plans, and falsifying therapy and treatment notes,” Wilson wrote.

“The fraud began with patient recruitment,” Wilson said. The company “solicited patients from hospital employees and owners of assisted living facilities in exchange for cash kickbacks. Many of these patients did not qualify for PHP treatment. Upon intake, HCSN employees altered patient profiles in order to conceal disqualifying information, such as evidence that patients suffered from Alzheimer’s disease or dementia. HCSN treated patients for inordinately long periods of time—generally at least four months—and then ‘recycled’ patients by discharging them and immediately admitting them to another HCSN location.”

Wilson said the therapists fabricated notes for absent patients, falsified details and “cloned” notes by copying and pasting from one patient’s file to another. The fraud included “ghost lists” and “ghost billing” for nonexistent patients and services that never took place, he said.

The panel came down particularly hard on the doctor. He was sentenced to 16 years in federal prison and ordered to pay $23 million in restitution. The judge bumped the sentence up under a “vulnerable victims enhancement” rule, which Wilson affirmed.

Wilson said that, more than anyone else at the company, “Rousseau was responsible for these patients: for reviewing their medical needs and qualifications for admission; for developing an individualized treatment plan for their conditions; for overseeing the implementation of treatment plans; and for monitoring each patient’s progress and eligibility for release. He admittedly abdicated all of that responsibility by signing ‘whatever medical documents they put in front of him,’ in furtherance of fraud, without regard to the underlying implications for patients’ health and well-being.”

The therapists were sentenced to five to six years in federal prison and ordered to pay $16 million each in restitution.

U.S. Attorney Benjamin Greenberg in Miami prosecuted the case. His office did not have any comment by deadline.

The defense team included Ken Swartz of Miami, Aubrey Webb of Coral Gables, Joaquin Mendez Jr. of Miami and Richard Klugh Jr. of Miami.

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