According to court documents, Zakia Khan and Ahsan Ijaz owned two Brooklyn-based social adult day care organizations, Happy Family Social Adult Day Care Center Inc. and Family Social Adult Day Care Center Inc., and a financial intermediary called Responsible Care Staffing Inc.

These organizations were involved in the New York Medicaid Consumer Directed Personal Assistance Services Program (CDPAP), which allows family members of Medicaid recipients to receive payment for helping the recipients with daily activities.

Starting around October 2017, marketers Elaine Antao, Omneah Hamdi and Manal Wasef reportedly directed Medicaid recipients to Happy Family, Family Social or Responsible Care in exchange for kickbacks and bribes. In return, the marketers allegedly paid kickbacks and bribes to Medicaid recipients for social adult day care and CDPAP services that the organizations billed to Medicaid – services they either did not provide or services that were influenced by those kickbacks and bribes.

Ansir Abassi, Ansir Zaib and Amran Hashmi purportedly managed Happy Family and Family Social along with the marketers. To carry out the kickback scheme, Khan, Antao, Ijaz, Abassi and Hamdi allegedly used business entities to launder the fraud proceeds and generate cash to pay kickbacks and bribes. Seema Memon, an employee of Happy Family who was previously charged by complaint on July 1, was also indicted.

“As alleged in the indictment, these defendants orchestrated a years-long scheme to defraud Medicaid of tens of millions of dollars for social adult day care and home care services that they did not provide,” Principal Deputy Assistant Attorney General Nicole M. Argentieri, head of the Justice Department’s Criminal Division, said in a statement. “The defendants allegedly paid cash bribes and kickbacks to recruiters and Medicaid recipients as part of a scheme to enrich themselves at the expense of vital programs for senior citizens. The charges make clear that the Criminal Division will not tolerate schemes that brazenly steal from federal health care programs.”

Khan has been charged with several offenses, including conspiracy to commit health care fraud, three counts of health care fraud, conspiracy to defraud the United States and to pay and receive health care kickbacks, paying health care kickbacks, conspiracy to commit money laundering, and money laundering. If found guilty, she could face a maximum penalty of 20 years in prison for each count of conspiracy to commit money laundering and money laundering, ten years in prison for each count of conspiracy to commit health care fraud, health care fraud, and paying health care kickbacks, and five years in prison for conspiracy to defraud the United States and to pay and receive health care kickbacks.

Abassi, Antao, Hamdi and Ijaz face charges of conspiracy to commit health care fraud, conspiracy to defraud the United States and to pay and receive health care kickbacks, conspiracy to commit money laundering and money laundering. If found guilty, they could be sentenced to a maximum of 20 years for each count of conspiracy to commit money laundering and money laundering, ten years for conspiracy to commit health care fraud, and five years for conspiracy to defraud the United States and to pay and receive health care kickbacks.

Hashmi is facing charges of conspiracy to commit health care fraud, three counts of health care fraud, conspiracy to defraud the United States, and paying and receiving health care kickbacks. If found guilty, he could be sentenced to a maximum of ten years for each count of conspiracy to commit health care fraud, health care fraud, and paying health care kickbacks, as well as five years for conspiracy to defraud the United States and to pay and receive health care kickbacks.

Memon is charged with conspiracy to commit health care fraud, conspiracy to defraud the United States, and paying and receiving health care kickbacks. If convicted, she faces a maximum penalty of ten years for each count of conspiracy to commit health care fraud and paying health care kickbacks and five years for conspiracy to defraud the United States and pay and receive health care kickbacks.

Wasef faces charges of conspiracy to commit health care fraud, conspiracy to defraud the United States, and conspiracy to pay and receive health care kickbacks. If found guilty, she could face a maximum penalty of ten years for conspiracy to commit health care fraud and five years for conspiracy to defraud the United States and to pay and receive health care kickbacks.

Since March 2007, the Health Care Fraud Strike program, consisting of nine strike forces operating in 27 federal districts, has prosecuted over 5,400 defendants who have overbilled federal health care programs and private insurers by over $27 billion.

“The crimes outlined in this indictment took advantage of a network that offers essential health care and other services to those in need,” Interim Commissioner Thomas G. Donlon of the New York City Police Department (NYPD) said in a statement. “Let it be clear: anyone who attempts to profit by defrauding the system will face consequences, as these schemes drain already limited resources and deprive beneficiaries of crucial funds. I commend our NYPD investigators and federal law enforcement partners for their continued collaboration.”

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Specifically, Edison Home Health Care of New York and Preferred Home Healthcare of New York allegedly failed to pay full wages and benefits to over 25,000 workers, according to the New York State Attorney General’s office.

The two agencies and their former operators will pay $7.5 million out to the over 25,000 workers. They will also pay $9.75 million back to Medicaid. It represents the largest wage parity settlement ever secured by the Office of the Attorney General and the Eastern District of New York.

Help at Home acquired both Edison Home Health Care and Preferred Home Healthcare in 2022, but a spokesperson for the company told Home Health Care News that the violations occurred prior to the acquisition.

“Home health aides provide crucial care to our most vulnerable neighbors and loved ones, and they deserve to be paid for their hard work,” James said in a statement. “Edison and Preferred cheated employees out of years of pay and cheated New York taxpayers by defrauding Medicaid for their own benefit. This is a tremendous victory for our ongoing efforts to protect hardworking New Yorkers’ rightfully earned wages.”

The New York Wage Parity Act, which was established in 2012, “was created to ensure home health aides receive fair compensation and benefits for their hard work,” a press release on the settlement read.

The investigation found that the two agencies failed to pay workers the full benefits they were owed under the Wage Parity Act, instead using those funds to purchase medical “stop loss” insurance, “which is a type of insurance that acts as a safety net for employers that are paying for their employees’ medical claims.”

What’s more, “individuals and entities” related to the two agencies received millions of dollars in dividend payments from that insurance, which “effectively served as a means of siphoning away funds intended for employees.”

“Edison and Preferred then continued to seek and receive payments from Medicaid for care performed by home health aides, while falsely representing that they were in compliance with the Wage Parity Act,” the release read.

As part of the settlement, Edison Home Health Care and Preferred Home Healthcare will revise company policies and procedures. They will also “regularly report staff wages and policy implementations” to the attorney general’s office for three years.

If the agencies fall out of compliance, the attorney general has the authority to bring further civil action against them.

Of the $9.75 million that will be paid out to Medicaid, $5.85 million will go to New York state. The other $3.9 million will go to the federal government.

“Home health aides work long hours at difficult, often thankless tasks to ensure that the vulnerable individuals who they provide services to are properly cared for,” Peace said in a statement. “These aides deserve the hard-earned benefits guaranteed to them under the law and my office will ensure that they are accurately compensated.”

In acquiring Edison Home Health Care and Preferred Home Healthcare, Help at Home made an entrance into New York for the first time.

The acquisitions added 10,500 new clients and 12,000 new employees to the company’s portfolio.

“As the leading provider of high-quality, Medicaid home- and community-based services, Help at Home has a 50-year history providing high quality, in-home personal care services in the communities we serve,” Help at Home told Home Health Care News in a statement. “The matter outlined in the agreements took place prior to the 2022 acquisition of Preferred Home Care of NY and Edison Home Health Care. We approached these matters with the utmost seriousness, implementing new rigorous protocols and benefit compliance processes, ensuring the companies met and continue to meet Help at Home’s best-in-class standards. We remain committed to our deep-rooted ‘caring for the caregiver’ culture and providing person-centered care that enables our clients to live as independently as possible in their own homes.”

Based in Chicago, Help at Home provides home- and community-based services (HCBS) to over 70,000 clients monthly across 11 states and more than 200 locations.

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Noli and Isabel Tcruz of Washington Township, Michigan, were sentenced on Sept. 4. Noli Tcruz received six years in prison, and his wife was given three years and two months.

The Tcruzes were convicted and sentenced for schemes related to their operation of several Macomb County home health care companies. These companies purported to provide legitimate medical care to Medicare beneficiaries but engaged in fraud.

“My office will diligently investigate and prosecute all types of fraud driven by greed,” U.S. Attorney Ison said in a statement. “Noli and Isabel Tcruz’s fraud harmed taxpayers and the government programs our tax dollars fund, including Medicare and COVID-19 programs. Health care professionals and providers have an opportunity and a duty to help people lawfully. Still, we will not hesitate to pursue individuals like these defendants who breach those duties to line their own pockets.”

The Tcruzes were involved in a roughly $5 million scheme to illegally offer kickbacks and bribes in exchange for referrals for home health care for Medicare beneficiaries. They also failed to pay their personal and business taxes.

After their last home health company closed in February 2020, Noli Tcruz began committing COVID-19 program fraud. He used a family member’s identity and company to deceive and defraud the Small Business Administration and Health and Human Services, obtaining over $250,000 in pandemic assistance funds.

Two physicians, Dr. Terry Baul and Dr. David Calderone, admitted to accepting kickbacks and bribes in exchange for referring Medicare beneficiaries to the Tcruzes. As part of their plea agreements, the two physicians were required to pay more than $3 million in restitution and forfeiture judgments. Additionally, they have been excluded from participating in Medicare and other federal health care programs.

“Paying kickbacks to induce referrals for medical services in federal health care programs is illegal and can lead to the delivery of unnecessary services, wasting valuable taxpayer funds,” Mario M. Pinto, Special Agent in Charge of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) said in a statement. “HHS-OIG will continue collaborating with our law enforcement partners to ensure that those who engage in unlawful kickback schemes in our federal health care programs are held accountable.”

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Guardian Health Care, Gem City Home Care and Care Connection of Cincinnati were the alleged agencies involved in the scheme.

The Anti-Kickback Statute “prohibits the provision of remuneration with the intent to induce referrals of government health care program business.” The above agencies allegedly violated the statute from 2013 to 2022 in Texas, Ohio and Indiana.

The kickbacks specifically came in the form of wellness health services, sports tickets and meals, all in exchange for Medicare beneficiary referrals.

“It is imperative to ensure that improper financial incentives play no role in decisions regarding patient care,”Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division, said in a statement. “Today’s resolution demonstrates the department’s commitment to protecting the integrity of federal health care programs and the medical treatment received by their beneficiaries.”

The claims resolved by the settlement are “allegations only,” investigators said. 

Last month, a Cincinnati-based home health agency owner racked up $8.5 Million in fraudulent claims and hired employees with a criminal history.

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From 2015 to 2021, Sharon Romaine Ward submitted at least 92,770 claims on behalf of Halo Home Healthcare to Medicaid, and received $8.4 million between 2016 and 2021. She also admitted that she concealed her ownership of that company because of a prior felony conviction.

Specifically, that conviction – in 2013 – was due to passing forged and fraudulent prescriptions for oxycodone and hydrocodone while serving as a nurse practitioner. Such a conviction would have made her ineligible to participate in federal health care programs for ten years, according to the U.S. Attorney’s Office.

Ward also failed to provide “accurate information to her business tax return preparer causing false tax returns to be prepared and filed.”

Halo Home Healthcare not only routinely overbilled federal health care programs and charged them for unperformed services, but also hired over 50 employees “with significant criminal histories,” which should have rendered them ineligible to provide home health services.

One such employee was even charged with a quadruple murder while working for Halo Home Healthcare, according to investigators.

Ward pleaded guilty this week to one count of health care fraud, as well as one count of making a false income tax return. The former charge is punishable by up to ten years in federal prison, while the latter is punishable by up to three years in prison. The plea agreement included a recommendation that the health care fraud charge not result in more than five years in prison.

“The agreement also calls for Ward to pay restitution to the Department of Veterans Affairs and the Ohio Department of Medicaid in an amount to be determined at sentencing,” the U.S. Attorney’s Office of the Southern District of Ohio wrote in a press release. “Ward also agreed to prepare and file corrected business tax returns with the IRS and pay restitution, plus any interest and penalties. The IRS determined a tax loss of $81,617.”

The case was investigated by the U.S. Department of Health and Human Services, the U.S. Secret Services, the Internal Revenue Service Criminal Criminal Investigation, the U.S. Department of Veterans Affairs Office of Inspector General and Ohio Attorney General Dave Yost’s Health Care Fraud Section.

In March, discrepancies in home health enrollment data raised red flags at a Congressional hearing.

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Rep. Michelle Steel (R-Calif.) grilled the secretary about an apparent lack of progress on curbing certifications for bad actors.

Steel also pointed to a potential discrepancy in the way home health agencies are accounted for, and how HHS and the the Centers for Medicare & Medicaid Services (CMS) tracks enrollment data.

The system in question is Quality, Certification, and Oversight Reports — also known as QCOR.

QCOR is an online reporting platform under CMS that allows the public to access timely and summarized data about providers and suppliers of both Medicare and Medicaid services. Information in QCOR includes provider names, addresses, sizes, ownership details and other general information.

According to Rep. Steel’s questioning, QCOR has not updated its information since early 2021 due to a system migration issue.

“My question here is, the public has a right to know what providers are enrolled in the Medicare program and it is completely unacceptable that the public-facing website has not been operational since 2021,” Steel said. “Can you explain why this has occurred and why the agency proceeded with enrolling over 800 new home health agencies in California?”

Though he pledged more detailed responses at a later date, Becerra told lawmakers that he was mostly unaware of what Steel was referring to and pledged to continue program integrity efforts.

“Congresswoman, what you’re presenting to me is something that I’ve not heard so I’ll have to get back to you on that,” Becerra said. “I will tell you, just as we were in our discussion about hospice care, home health care — which is a growing industry as well — is something that we’re trying to monitor more closely. We are constantly doing program integrity work in this field as well. We could try to respond more specifically to any questions you have, but what you’ve just mentioned does not sound familiar to me.”

In recent years, there has been a significant increase in the number of hospice providers enrolled in Medicare, particularly in Arizona, California, Nevada and Texas.

In some instances, multiple hospices have been operating from the same address without a corresponding increase in the population of eligible patients.

The surge in enrollment has raised concerns about potential fraudulent activities. One county in particular is once again in the spotlight: Los Angeles County.

What Steel referred to during Wednesday’s hearing was a discrepancy between QCOR figures and raw enrollment data sets made public by CMS.

There are 11,353 home health agencies enrolled in the QCOR data set and 11,577 enrolled in CMS’ raw data set.

Even though the totals aren’t far off from each other, there has been a significant shift in the locations of the home health agencies.

CMS enrolled 839 home health agencies from 2021 to 2023, according to data shared with Home Health Care News on background. Of those, more than 700 were listed in Los Angeles County alone.

However, there is no information about those agencies in the public-facing QCOR website.

“I can make sure that we give you a more complete answer than what I can give you right now,” Becerra said during the hearing. “Some of [these bad actors] go out and do things that are against the law or do things fraudulently, there’s no doubt that’s one of the reasons why under Medicare or Medicaid we are constantly trying to root out that fraud.”

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Between 2014 and 2023, personal care services accounted for at least 34% of fraud convictions in some years and as much as 48% in other years.

That’s according to a new report from OIG that detailed the findings from Medicaid Fraud Control Units (MFCUs). MFCUs are mandated by the Social Security Act to investigate and prosecute Medicaid provider fraud and patient abuse or neglect.

MFCUs are in all 50 states and are jointly funded by the federal and state governments.

In fiscal year 2023, these units reported 1,143 convictions, which, while higher than in FY 2020, remained lower than pre-pandemic levels. The number of convictions had steadily declined during FY 2020 — aligning with the onset of the COVID-19 pandemic — which indicates a “sustained impact on enforcement activities,” OIG wrote in its report.

However, there seems to be ongoing issues related to fraud in personal care.

While personal care attendants made up a significant amount of convictions, they also represented a higher percentage than all other provider types.

In FY 2023, OIG found personal care services accounted for 279 convictions compared to 66 for nurses, 43 for home health agencies, 33 for ophthalmologists and 36 for mental health facilities.

The OIG report cited 43 criminal convictions from home health agencies and 26 civil settlements in 2023.

Of the dozens of provider types listed in the report, home health fraud convictions totaled the highest in recoveries at $34.6 million. Other notable provider types near the top of the list were surgeons ($26.8 million), personal care service agencies ($26.4 million) and suppliers of durable medical equipment ($23.6 million).

The 1,143 criminal convictions totaled $272 million in recoveries and the 436 civil settlements totaled about $962 million.

This week, Family First Home Health Care, a personal care agency based in North Carolina, reached a settlement of $600,000 to settle accusations of submitting fraudulent Medicaid claims from 2015 to 2020, which violated both federal and North Carolina False Claims Acts.

The government alleged that Family First and its owner Marion James billed Medicaid for in-home personal care services that were never performed on days when patients were hospitalized.

As for the federal government’s crackdown of these cases, the crime units seem to be paying off.

“The amount of civil recoveries reached a 4-year high in 2023 and the combined criminal and civil recoveries were $1.2 billion, resulting in an ROI of $3.35 for every $1 spent,” the OIG reported.

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The Wisconsin-based Atlantic Home Health Care (AHH) is a home health care agency that operates in nine states. The U.S. government alleges that in Arizona, between 2017 and 2021, the agency falsely billed a government energy program for in-home nursing and personal care services that were never provided.

The government also alleged the agency paid kickbacks through its “friends and family program,” offering cash payments of up to $5,000 for patient referrals. Additionally, the agency provided payments for expenses like food, internet and travel to patients and their families.

These actions were considered a violation of the Anti-Kickback Statute, which prohibits parties in federal health care programs from “knowingly paying or receiving remuneration for patient referrals,” according to a press release from the U.S. Department of Justice.

“Quality care is critical to beneficiaries participating in the Energy Employees Occupational Illness Compensation Program (EEOICP),” U.S. Attorney Gary Restaino, for the District of Arizona, said in a statement. “The payment of cash kickbacks to induce referrals has no place in our health care system. False Claims Act enforcement protects the integrity of federal health care programs.”

The EEOICP was established to protect the interests of Department of Energy employees or contractors who were injured or became ill on the job.

Atlantic Home Health Care disclosed its wrongdoing voluntarily before the government investigated, and the settlement acknowledged its cooperation.

Of the settlement total, approximately $7 million will be restitution. The case also involved a former agency employee, Tonya Cass, who filed a whistleblower lawsuit. As part of the resolution, Cass will receive about $1.7 million.

The resolution of the case comes after years of work and coordination between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section and the U.S. Attorney’s Office for the District of Arizona.

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As part of the agreement, Cigna will pay more than $172 million to the government and will also enter into a corporate integrity agreement with the U.S. Department of Health and Human Services Office of the Inspector General (OIG).

Among the allegations, the government said Cigna used vendors to do in-home assessments of its plan members, but the nurses failed to do the tests or imaging necessary to accurately diagnose serious conditions.

Afterward, Cigna billed Medicare using billing codes associated with conditions for these unconfirmed diagnoses to secure higher payments.

“For years, Cigna submitted to the government false and invalid diagnosis information for its Medicare Advantage plan members,” Damian Williams, U. S. attorney for the Southern District of New York, said in a statement. “The reported diagnoses of serious and complex conditions were based solely on cursory in-home assessments by providers who did not perform necessary diagnostic testing and imaging. Cigna knew that these diagnoses would increase its Medicare Advantage payments by making its plan members appear sicker.”

Bloomfield, Connecticut-based Cigna is one of the largest health insurance companies in the country. It contracts with other organizations that offer certain services and products to Cigna plan participants.

Last year, the federal government filed a lawsuit against Cigna, claiming that the insurance company’s MA plans submitted inaccurate and untruthful codes between 2016 and 2021. By failing to delete or withdraw incorrect codes, the federal government sued Cigna for violating the False Claims Act.

During that time, Cigna ran a “chart review” program — going through medical records of Medicare beneficiaries in their plans. The company hired coders to find medical conditions and assign diagnosis codes, among other things.

Cigna allegedly used this process to add codes for conditions that providers hadn’t reported, aiming for more payments. The government also accused the company of failing to validate some codes

As part of the agreement, top executives and members of Cigna’s board must make certifications about the company’s compliance measures.

“These agreements fully resolve long-running legal matters enabling us to focus our resources on all those we serve and avoid the uncertainty and further expense of protracted litigation,” Chris DeRosa, president of Cigna Healthcare’s U.S. government business, said in a statement. “We are pleased to move beyond industry-wide legal disputes related to past risk adjustment practices, and we look forward to continuing to provide high-quality, affordable Medicare Advantage coverage to our customers and delivering value to the taxpayers in the years ahead.”

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The conviction was brought down by a federal jury in Miami this week.

The two people convicted — Karel Felipe and Tamara Quicutis — submitted false bills to Medicare for three home health companies located in Michigan from October 2016 to May 2019.

The co-conspirators recruited people from Cuba to sign Medicare enrollment documents and act as the owners of the home health agencies.

Felipe and Quicutis then used a list of stolen patient identities to bill for home health services, according to court documents.

In order to receive the federal funds, Felipe and Quicutis used hundreds of shell companies and bank accounts to launder the money and convert the proceeds into cash at ATMs and check cashing stores in Miami.

Fraud in home health is far from new, especially in parts of Florida.

Researchers at Dartmouth’s Geisel School of Medicine recently discovered that home health agencies that share patients across multiple agencies, and those that had high rates of expenditures across hospital referral regions (HRRs), were more likely to commit fraud than others.

While Medicare spending on home health services naturally grew from 2002 to 2009, the massive increases were highly concentrated in just a few regions of the U.S.

For example, in the Miami region, home health expenditures rose 302% from $802 in 2002 to $3,229 per Medicare enrollee in 2009.

In comparison, home health billing in Los Angeles saw a significantly smaller increase from $782 in 2002 to $861 in 2009.

The jury convicted Felipe and Quicutis on two felony counts: conspiracy to commit health care fraud and wire fraud, and conspiracy to commit money laundering.

They are scheduled to be sentenced at the beginning of 2024 and both face a maximum of 20 years in prison on each conspiracy charge.

A third defendant, Jesus Trujillo, pleaded guilty to one count of conspiring to commit health care fraud and wire fraud and one count of conspiring to commit money laundering.

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