Medicare Fraud Culprit Going to Jail

Sometimes there is justice:

A Florida healthcare executive was sentenced Thursday to 20 years in prison for orchestrating what prosecutors described as a massive $1 billion Medicare fraud scheme.

U.S. District Judge Robert Scola imposed the sentence on Philip Esformes, 50, in one of the biggest such cases in U.S. history.

Trial testimony showed the wealthy Miami Beach businessman operated a network of nursing homes and assisted living facilities in South Florida that jurors found used kickbacks and bribes to gain business.

‘People who needed care, people who wanted to get better, they had no shot,” said Assistant U.S. Attorney Allan Medina. “The nature of the fraud, the conspiracy, the money-laundering scheme, was atrocious.”

Esformes was convicted by a jury in April of 20 charges including money laundering, receiving healthcare kickbacks, bribery conspiracy and obstruction of justice. Prosecutors are also seeking forfeiture of $38.5 million in assets.

How many more Philip Esformes are there out there? I bet a lot. Why is that you never see the insurers, like Anthem or UnitedHealthcare, getting ripped off by these people? Why is it just the government?

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Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected]om 

  5 comments for “Medicare Fraud Culprit Going to Jail

  1. Joe
    September 29, 2019 at 8:26 pm

    Because the government at this point is innately corrupt and extremely well suited to squander and fraud.

  2. R Stuart
    September 22, 2019 at 2:13 pm

    “Why is that you never see the insurers, like Anthem or UnitedHealthcare, getting ripped off by these people?”

    Anthem and United just make the 100 million dollar payments directly to their CEOs and CFOs. Much simpler for all involved.

  3. Pat
    September 22, 2019 at 12:40 pm

    Where you have large piles of government cash, you will have fraud. When the fraud is discovered, it usually results in more limitations, scrutiny, and preemptive punishment of innocents.

    The only real fix would be to get government out of health care. So we will have this corruption forever.

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  4. stevem64
    September 21, 2019 at 1:35 pm

    The answer to your question:
    Anthem and the other private insurers DO get ripped off regularly. A few years back, a local doctor operated a bogus Surgery Center and collected massive fraudulent fees from the big insurers. It was going on for years! A few savvy patients complained, but the insurers did nothing. It wasn’t until people complained to Medicare that action started happening. For the insurers, the cost of doing an investigation was simply too high. Often, they just silently pull back and begin denying claims. One of the shocking things about our local case was how long this had been going on with the private insurers and how little interest was shown in taking action.
    So, it is not just the government as the victim. It’s the one you hear about, though. I suspect it relates to having an existing mechanism (though insanely slow and plodding) to investigate government fraud and abuse.

    • Holly
      September 25, 2019 at 10:10 am

      I keep thinking that contract and commerce laws may be applicable in some of these cases. The plaintiff would be the employer, who based on the insurance providers marketing material, was led to believe that the insurance company would provide excellent financial management and medical oversight. Obviously in this egregious case of the surgical center, they did not.

      In this and all such instances, both the financial and medical variables that point to excessive medical services were (and still are) in their database, hence it would not be difficult to find the health insurance company did not live up to its end of the contractual agreement, and/or used false marketing material regarding their financial and medical oversight. It all depends on the jurisdictions contract / commerce regulations but often whoever breaks the contract first loses all protections granted from the document, so all other “provisions,” such as mandated mitigation may become null and void.

      Of course the big issue with this idea is that you would need many employers to sue, or the employer must obtain enough of a financial settlement to compensate for future bogus “high risk” premium hikes.

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