Florida Agency Changes Policy Amid $1 Billion Medicare SNF Fraud Bust

The Florida Agency for Health Care Administration (AHCA) tightened its internal protocols after a former administrator was charged in connection with what the Department of Justice is calling the largest health care fraud on record.

Bertha Blanco worked for the Florida AHCA for 29 years before she was fired in late 2016. She has now been charged with accepting tens of thousands of dollars in bribes in exchange for sharing confidential agency information, including patient complaints and the dates of unannounced inspections at Miami-area skilled nursing facilities, the Miami Herald reports.

Blanco was a small part of a long-running Medicare fraud scheme coordinated by Philip Esformes, owner of more than 30 Esformes Network skilled nursing and assisted living facilities in the Miami area. The scam resulted in losses in excess of $1 billion, according to a press release from the Department of Justice.

“This is the largest single criminal health care fraud case ever brought against individuals by the Department of Justice, and this is further evidence of how successful data-driven law enforcement has been as a tool in the ongoing fight against health care fraud,” said Assistant Attorney General Leslie R. Caldwell in the release.

The Florida AHCA has responded by putting stricter policies in place to prevent future fraud in the agency.

“As a result of this incident, access to [Florida Agency for Health Care Administration] inspection dates has been tightened, and is now limited only to those required to know,” Agency Press Secretary Shelisha Coleman told Skilled Nursing News.

“Dates are kept in systems with tight security controls and limited access. Future dates are masked to users without specific permission, to reduce the chance of this ever happening again. Each person that has access to this information is required to sign a certification acknowledging the penalties for inappropriate disclosure. Other safeguards include extensive training of confidentiality expectations related to inspections and other sensitive information, and routine audits.”

The agency holds all employees to high standards, Coleman said, and when those are not met, the agency will take the appropriate action necessary to ensure the health and safety of the patients at the health care facilities that it regulates.

According to the indictment, Esformes had access to thousands of Medicare and Medicaid beneficiaries, many of which did not quality for skilled nursing home care. However, he and his co-conspirators admitted them to Esformes Network facilities where they received medically unnecessary services that were billed to Medicare and Medicaid.

Esformes and others involved in the scam also received kickbacks to steer these beneficiaries to other health care providers who also performed medically unnecessary treatments that were billed to Medicare and Medicaid.

Esformes’ trial has been set for September 18.

The Department of Justice commented in a press release on its priority to root out this type of fraud in the future.

“Medicare fraud has infected every facet of our health care system,” said U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida in the release. “As a result of our unrelenting efforts to combat these pernicious schemes, the Criminal Division, the U.S. Attorney’s Office and our law enforcement partners continue to identify and prosecute the criminals who, driven by greed, steal from a program meant for our aged and infirmed to increase their personal wealth.”

Written by Elizabeth Jakaitis

Elizabeth Jakaitis

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