Enforcement actions mount in partial hospitalization fraud cases

The operator of community health centers in Louisiana and a patient recruiter for a community mental health center in Texas were sent to prison for their roles in a multimillion-dollar Medicare fraud scheme, the FBI announced. This case is one of many recent fraud prosecutions involving partial hospitalization program services.

Roslyn F. Dogan recruited beneficiaries in Baton Rouge to attend partial hospitalization service programs knowing the patients didn't need psychotherapy. She arranged to keep them at facilities for as long as possible without triggering Medicare audits, the FBI noted. Dogan also directed staff to alter records to make it look as if patients received psychotherapy when they didn't.

James R. Hunter recruited beneficiaries to attend a partial hospitalization program in Houston in exchange for cash payments of $1,500 per week. He recruited patients who were ineligible for partial hospitalization, paying them $75 per week.

Dogan and Hunter received prison sentences of 90 and 60 months, respectively. Three companies involved in this case collectively filed more than $258 million in inappropriate Medicare claims. Seventeen people have been convicted in this case. And psychiatrist Zahid Imran, M.D., co-owner of the Louisiana community health centers and the Houston facility, pleaded guilty to conspiracy to commit healthcare fraud and was sent to prison, the Miami Herald reported.

Also in Houston, a federal grand jury convicted Earnest Gibson III, president of Riverside General Hospital, and three others for participating in a $158 million partial hospitalization scam. The treatment provided was a sham: Some beneficiaries watched television all day, others had dementia and couldn't understand the therapy they supposedly received and others never went to the hospital.

And in Medicaid, there's been "an explosion of fraud in community-based treatments," including billing for services not rendered, services provided by unlicensed staff or services tainted by kickbacks, according to Assistant U.S. Attorney Ted Radway.

Finally, a Miami federal jury convicted Roger Bergman and Rodolfo Santaya--a physician assistant and a certified nursing assistant who worked for a mental healthcare company--for participating in a Medicare fraud billed out at $200 million. Bergman falsified documentation to make it appear that patients qualified for and received partial hospitalization care when they actually didn't. Santaya received hundreds of thousands of dollars in kickbacks for bringing ineligible beneficiaries to the company.

For more:
- here's the FBI announcement
- read the Miami Herald article