Unnecessary medical bills charged in the Philip Esformes Medicare fraud case

Billion-Dollar Medicare Fraud Case Focuses on Miami Nursing Homes

One of the largest Medicare fraud cases on record is currently underway in Florida, and it has assisted living facilities at its center.

In 2016, FBI agents arrested Philip Esformes, owner of more than 30 Miami-area nursing and assisted living facilities, Odette Barcha, former director of outreach programs at Larkin Community Hospital in South Miami, and Arnaldo Carmouze, a physician’s assistant, in what the U.S. Department of Justice (DOJ) called “the largest single criminal health care fraud case” it has “ever brought against individuals.”

According to a 2016 news release from the DOJ, Esformes and his co-conspirators, as they are referred to in the document, were charged with “conspiracy, obstruction, money laundering and health care fraud in connection with a $1 billion scheme involving numerous Miami-based health care providers.”

The indictment alleges Esformes and his co-conspirators admitted thousands of Medicare- and Medicaid-covered individuals to his nursing homes and assisted living facilities — called the Esformes Network — where they “received medically unnecessary services that were billed to Medicare and Medicaid.” In addition, they accepted kickbacks for steering patients to other health care providers where medically unnecessary treatments were administered and billed.

A court filing cited by CNBC noted that Esformes and his co-conspirators also “preyed upon his beneficiaries addictions by providing them with narcotics so that the beneficiaries would remain in Esformes Network facilities, allowing the cycle of fraud [to] continue.”

The scheme, according to the Miami Herald, included $450 million in false claims to Medicare and Medicaid $36 million of which Esformes personally pocketed. Esformes has made payouts in similar cases in 2006 and 2013, CNBC reported.

“It happened over and over and over again,” Assistant U.S. Attorney Elizabeth Young told the jury during opening arguments on Feb. 12, the Tampa Bay Times reported. “Rinse and repeat. And it happened for 10 years.”

Only Esformes, who, the Miami Herald reported has been in federal prison since his arrest, is on trial; Barcha and Carmouze have already pleaded guilty to charges.

Barcha testified against Esformes on Feb. 13 at which time she detailed how she and others accepted bribes to refer patients to Esformes’ facilities, Law360 reported. Barcha faces 3 ½ years in prison and Carmouze faces eight years, the Miami Herald noted in January.

If Esformes is found guilty, he could spend the rest of his life in prison, the Miami Herald reported. His trial is excepted to take two months, Law360 reported.