DELRAY BEACH, FL (BocaNewsNow.com) (From USDOJ) — A Delray Beach doctor has been charged with eight counts of health care fraud.
Wifredo A. Ferrer, U.S. Attorney for the Southern District of Florida, George L. Piro, Special Agent in Charge, FBI, Miami Field Office, and Derrick Jackson, Special Agent in Charge, U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG), made the announcement.
According to allegations in the indictment, Isaac Kojo Anakwah Thompson, M.D., 55, operated Isaac K. A. Thompson, M.D., P.A. in Delray Beach, and IM Medical P.A. in Boynton Beach, Florida. These clinics were Primary Care Physicians (PCP) in Humana’s HMO network. Therefore, a beneficiary enrolled in a Humana health maintenance organization (HMO) Medicare Advantage plan could choose Thompson’s clinics as the beneficiary’s PCP. Humana paid each clinic approximately 80% of the capitated fee associated with each beneficiary who had selected the clinic as his or her PCP.
Thompson defrauded Medicare by submitting fraudulent diagnoses to Humana for Medicare Advantage beneficiaries. Humana reported the diagnoses to Medicare, and Medicare in turn increased the capitation payments associated with many of the beneficiaries. In total, Medicare paid at least approximately $2.1 million in excess capitation fees as a result of the scheme. Humana paid approximately 80% of the increased capitation payments to Thompson’s clinics. Because the diagnoses were false, Thompson did not have any corresponding increase in his cost to treat the patients.
According to the allegations in the indictment, the Medicare Advantage program is a voluntary program which allows Medicare beneficiaries to enroll in health insurance plans sponsored by private insurance companies. For each beneficiary who chooses to enroll in a Medicare Advantage plan, Medicare pays the sponsoring insurance company a fixed, or capitated, monthly fee. Medicare does not adjust the fee based on the cost of providing medical care to the beneficiary. Instead, Medicare adjusts the fee based on the beneficiary’s medical conditions. In other words, Medicare generally pays a larger capitated fee for a beneficiary with more serious medical conditions than it does for a healthier beneficiary. Medicare determines a beneficiary’s medical conditions in part using diagnoses submitted by the beneficiary’s Medicare Advantage plan. The fraud in this case involved certain Medicare Advantage plans sponsored by Humana, Inc. These Humana plans operated as HMO: each enrolled beneficiary selected a PCP enrolled in Humana’s network. Before seeing a specialist, the beneficiary generally needed a referral from his or her PCP.
If convicted, Thompson faces maximum possible statutory sentences of 10 years in prison for each count.
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