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Alan D. Bersin, United States Attorney, and William D. Gore, Special Agent in Charge, San Diego Division of the Federal Bureau of Investigation, announced the culmination of a massive two and one half year investigation code-named “Sure Buck.”
Indictments and arrests of 23 individuals from Mexico and Southern California were carried out in San Diego County.
The Federal Bureau of Investigation, in partnership with the National Insurance Crime Bureau (NICB) and private industry, has successfully identified, penetrated, indicted and arrested an international group of foreign and domestic providers and suppliers. These individuals are believed to operate both within and outside of the United States, defrauding US health care insurers.
The majority of arrest sites will not be disclosed in order to protect the integrity of the ongoing investigations. However, certain arrest and search locations can be disclosed, including:
Medical Provider Services (search location) 3130 Bonita Road,
Suite 108 Bonita, CA Arrestee: LeRoy Alexander
Medical Repair Center (search location) 8300 Center Street La
Mesa, CA Arrestees: David Painter Salvadore Vega
Wells Fargo Bank 5522 Balboa Avenue San Diego, CA
Arrestee: Paula Whitsell
Private residence of Minerva McGregor Chula Vista, CA
Bill Gore, FBI Special Agent in Charge, states, “I am proud of the accomplishments brought to light by our office. The challenge to federal investigators has been to develop an effective investigative strategy to address health care fraud schemes that are complex and multinational. This operation has successfully infiltrated the fraud being committed in our region, which was made more complex by the international border.”
Prior to the arrests in San Diego, US Justice Department officials briefed Mexican government authorities concerning the operation. The two governments pledged their support and cooperation in confronting crime in the White Collar fraud arena as they have in other areas. The PGR office in Los Angeles and the United States Attorney’s Office in San Diego, have established a liaison working group to monitor legal developments in this case and to consult as necessary and appropriate to resolve specific issues as they arise.
US Attorney Alan Bersin comments, “Prosecuting health care fraud is the Attorney General’s top priority on the White Collar Crime agenda. Operation Sure Buck demonstrates that insurance fraud and false billing cross border or otherwise will be detected, prosecuted, and punished in this region on a cooperative basis.”
The following is a special briefing package to showcase the operation and further detail the violations and issues.
BRIEFING
United States law enforcement is focusing on the problem of fraudulent health care claims, particularly hospitalization claims, made to US private insurers. Research has concluded that various US billing agencies/services used by physicians (also known as providers) in, for example, border towns along the southwest border, encourage foreign based physicians to utilize their services for fraudulent activities. Local private insurers suspect that physicians obtain patient identifiable information from friendly businesses and physicians in the US or the patients themselves who cut “deals” with foreign providers for a percentage of the paid claims. For example, a patient has plastic surgery and the procedure is billed to the insurance company as emergency medical services. Once patient identifiable information is obtained, the foreign physician utilizes American based billing services to submit the fraudulent claims. These billing agencies maintain American addresses (usually postal box addresses) and promise the foreign physicians faster payment and higher fees. The providers and billing agencies then submit bills which reflect grossly inflated charges and/or charges for services never provided. The profits collected are divided between the billing agency, the doctor, and in some cases, the patient.
In the past, American insurers have utilized private claims investigators in the United States to determine if suspect claims were fraudulent. However, over the past several years, most of the foreign providers and American billing agencies have been coaching their staffs and patients on what to tell insurance investigators inquiring about claims and past hospitalizations. Private insurers advise that facilities that provide experimental treatments have learned how to bill for traditional medicine in order to collect from insurers. Hospitals and clinics have been constructed outside the United States to thwart the rejection of claims by American insurers. Previously these claims weren’t paid because the medical facility was inadequate to treat the claimed ailment. All of this has made catching the frauds and perpetrators extremely difficult.
Most American insurers complain that have onsite reviews conducted at foreign clinics/hospitals by their investigators have revealed that these facilities did not have the equipment or facilities necessary to conduct the procedures for which they were billing the insurer. The insurers also complain that some of the patients, who their investigators were able to contact,advised that they had never received the treatment for which the billing agency submitted claims. Rather, the patients had gone to the foreign provider identified in the claim for only minor treatment. Insurers further advise that the foreign providers and their US billing agencies were engaged in
1. Misrepresenting services rendered.
2. Submitting charges for services not rendered.
3. Inflating fees to maximize insurance reimbursement; and,
4. Concealing the location of hospitals/clinics they represent.
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