From Law 360–More indicted in $45 million Medicare/Medicaid Scheme

https://www.law360.com/articles/873613/more-nurses-plead-guilty-in-45m-medicare-fraud-scheme

Law360, Springfield (December 16, 2016, 4:21 PM EST) — Two more nurses and an office manager pled guilty in Illinois federal court on Thursday to one count to commit health care fraud in litigation involving several Chicago-area home health care companies in a $45 million Medicare scheme.
Registered nurses Mary Mendoza and Ronald Malalis, along with office manager Janet Guerrero entered plea bargains in the alleged scheme run by the owners of Lincolnwood-based Pathways Home Health Services LLC, Donnarich Home Health Care Inc. and Josdan Home Health Care Inc. The owners of the three home health companies, Josephine, Richard and Maribel Tinimbang, are the alleged ringleaders, with help from staff.

In their time participating in the Tinimbangs’ scheme, Mendoza and Malalis allegedly made patients out to be sicker than they were, in order to gain a higher payout from the Medicare program. The nurses allegedly falsified patient care paperwork known as the Outcome and Assessment Information Set, or OASIS form.

“Defendant understood that the sicker the patient appeared to be on the OASIS form, the more the company was paid by Medicare,” Malalis’ plea bargain said. “Defendant also understood the patients he assessed were insured by Medicare, and that such patients were only eligible for home health care if they were homebound. Yet most of the beneficiaries defendant and others enrolled in home health care at Josdan and Pathways were not homebound.”

Mendoza’s plea bargain is similar, admitting she learned how to fraudulently fill out OASIS forms from a supervisor named Monette Mojares and an unnamed person referred to as “Supervisor B.”

“Defendant acknowledges that over the course of approximately two and a half years as a start-of-care nurse, defendant certified non-homebound beneficiaries for home health care more than 150 times, causing Medicare to pay Pathways more than $400,000 but not more than $500,000,” according to the Mendoza’s plea. Malalis’ plea included a similar statistic.

Both Mendoza and Malalis allegedly were pressured to fill out OASIS forms incorrectly in sweeping fashions, prescribing one ailment to many patients.

“Defendant’s supervisors told him to mark all women as incontinent because women have babies,” Malalis’ plea deal said. “Defendant’s supervisors also told him that he should not state on OASIS forms that a beneficiary had scores of ‘zero,’ indicating an ability to independently complete daily activities like walking.”

Both Malalis’ and Mendoza’s plea deals carry a maximum sentence of 10 years in prison and a top fine of $250,000.

In the case of Janet Guerrero, Thursday’s plea said Guerrero acknowledged that during her time as office manager of Josdan, she enrolled patients in home care services they did not need at the instruction of Josephine Tinimbang. Guerrero would aggressively contact Medicare beneficiaries who were referred to Donnarich and Josdan, according to her plea.

“The beneficiaries Guerrero spoke with often refused services or told her that they were driving, working, or otherwise able to leave the home regularly and without difficulty,” Guerrero’s plea said. “However, Guerrero was supervised by Josephine Tinimbang, and Tinimbang did not accept that beneficiaries who did not want, need, or qualify for services should not be enrolled. Tinimbang insisted that Guerrero and others make repeated attempts to persuade unqualified beneficiaries to accept the companies’ services, and Guerrero in fact did so.”

In total, 15 people who worked at or with the three companies were indicted as part of a wider crackdown by the Medicare Fraud Strike Force that the government announced in 2015 had swept up 243 individuals in 17 federal districts for Medicare fraud totaling $712 million.

The three Tinimbangs are scheduled to be tried in February, while some of the other Tinimbang health care agencies’ defendants have been given a September trial date. To date, four registered nurses and a president of one of the recruitment companies that sent patients to the agencies have also pled guilty.

Representatives from no parties could be reached for comment on Friday.

Mendoza is represented by Michael Falconer, attorney at law.

Malalis is represented by Gal Pissetzky of Pissetzky & Berliner and Michael Schmiege of the Law Offices of Michael P. Schmiege PC.

Guerrero is represented by MiAngel C. Cody of the Federal Defender Program.

The government is represented by Assistant U.S. Attorney Brooke Harper.

The case is USA v. Tinimbang, et al., case number 1:14-cr-00732, in the U.S. District Court for the Northern District of Illinois.

— Additional reporting by Diana Novak Jones and John Kennedy. Editing by Ben Guilfoy.

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3 thoughts on “From Law 360–More indicted in $45 million Medicare/Medicaid Scheme

    • Thanks for the comment. That’s how corruption works. All the elderly need hospice and until then all women are incontinent and need more services. It’s nothing but fraud, waste and mismanagement. Why does it take the US govt years to prosecute tho?

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