United States: Health Care Fraud And Abuse In The Middle District Of Florida In 2016 - A Year In Review

Last Updated: March 4 2017
Article by Edward J. Page

The United States Attorney's Office (USAO) for the Middle District of Florida (USAO-MDFL) prosecuted several civil health care fraud matters in 2016 and issued related press releases. A review of the USAO-MDFL's criminal and civil health care fraud matters, as detailed in 24 of its 2016 press releases, helps predict where the USAO-MDFL will focus its health care enforcement efforts this year and beyond. This article organizes the USAO-MDFL's 2016 health care fraud matters by category and topic and offers pointers for health care providers within the USAO-MDFL's jurisdiction and elsewhere as we move into 2017.


The USA0-MDFL has various tools to combat health care fraud, and used many of them in 2016. They include: (1) federal criminal prosecutions with prison, fines, and asset forfeiture; (2) False Claims Act civil actions that result in civil settlements but which can also lead to criminal investigations and related criminal prosecutions; (3) debarment, which keeps health care providers from providing health care services under various federal health care benefit programs; (4) pure asset forfeiture; (5) search warrants; (6) seizure warrants for bank accounts that hold funds derived from the alleged health care fraud; and, (7) suspension authority in the Affordable Care Act, which excludes health care providers from participating in the Medicare reimbursement program.

Companies and Individuals Targeted

In 2016, the USAO-MDFL brought criminal and civil cases against both companies and individuals. It focused on durable medical equipment providers; pharmacies; hospitals; home health care providers; medical clinics that billed for radiology, audiology, cardiology, and neurology services; a radiation oncology provider; unlicensed chiropractic clinics; infusion clinics; telemarketing call centers; urgent medical care clinics; prescription compounding pharmacies; physicians groups; skilled nursing facilities; a cancer treatment clinic; an orthopedic medical group; and a pharmaceutical company. 

It also took action against individual cardiologists, pain management physicians, general practice physicians, neurologists, home health care owners, a medical director, health care clinic physicians, persons who allegedly served as sham medical directors conducting quality reviews of patient charts, chiropractors, registered nurses, licensed pharmacists, physician's assistants, business owners, infusion clinic owners, individuals no longer on Social Security Disability or who became ineligible and continued to receive such disability payments, urgent care medical doctors, licensed osteopathic doctors, an owner of a skilled nursing facility, and others.

While it appears the USAO-MDFL did not single out a lawyer for attention in 2016, it has in the recent past. The USAO-MDFL's scrutiny of individuals is consistent with the U.S. Department of Justice's September 9, 2015 Yates Memo, which emphasized that justice must be meted out to both the corporation involved in the fraud and abuse and the "individuals who perpetrated the wrongdoing."

The USAO-MDFL does not focus on particular health care practices, specialties, or industries, but rather on the underlying facts uncovered in investigations to determine if health care fraud and abuse exists. This is why such a broad range of businesses and individuals are involved in the matters noted in the USAO-MDFL's's 2016 press releases.

Federal Health Care Programs Involved

in 2016, as in past years, the USAO-MDFL prosecuted health care fraud and abuse matters that impacted Medicare, Medicaid, TRICARE (the U.S. military health care program), and the Federal Employees Health Benefits Program. 

The USAO-MDFL does not focus on a particular health care benefit program. The health care matters mentioned in the 2016 USAO-MDFL press releases were distributed among the major federal health care programs.

Federal Statutes Allegedly Violated

Numerous statutes are used to prosecute individuals and companies for health care fraud. False statements submitted to the government for Medicare payments may be prosecuted under the false statement statute, the false claims statute, or the mail fraud statute. For kickbacks, the government may also proceed under 18 Title 42 U.S.C. Section 1320a-7b(b), which outlaws any payment for a referral of a Medicare patient. Finally, 18 U.S.C Section 1347 makes it a crime to engage in a scheme to defraud any health care benefit program. These are just some of the federal statutes in the USAO-MDFL's toolbox.

While the USAO-MDFL must prove the elements of any statutes beyond a reasonable doubt, it is rarely difficult to do so in "fraud at the outset" cases (where fraud is planned at the outset). It is more challenging in the "optimization" type matter, which seeks to discern bad or criminal intent from billing practices or other business methods that may or may not withstand scrutiny.

Numerous Federal Investigators Handled the 2016 Matters

Many federal agencies have the authority to investigate health care fraud matters. Those that did so in 2016 included the FBI, Health and Human Services Office of the Inspector General (HHS-OIG), Defense Criminal Investigative Services, Veterans Affairs Office, Office of Personnel Management, Florida's Department of Financial Services Division, the Internal Revenue Service, and the Social Security Office of the Inspector General.

The USAO-MDFL Team Approach

In past years, the USAO-MDFL organized into teams to bring civil and criminal prosecutions. These teams include Health Care Fraud Prevention and Enforcement, Medicare Fraud Task Force, and the National Health Care Fraud Initiative.

How the USAO-MDFL Detected Alleged Health Care Fraud

Detection methods included: voluntary disclosure by the company engaged in the alleged fraud; former employees (False Claim Act "relators") who reported the fraud to the USAO- MDFL; tipsters; and outlier analysis by Medicare (the "proactive review of claims data" that revealed the provider "was a statistical outlier in terms of billing for" the services for which they billed Medicare). 

Financial Rewards for Relators/Tipsters

Former employees who reported alleged fraud included a medical doctor, a physicist, and a former medical assistant. Their rewards ranged from $37,500 to $29 million. Of the 24 health care fraud matters for which the USAO-MDFL issued 2016 press releases, it appears that about five relators were involved. A relator is simply someone who brings a lawsuit against a defendant in the government's name.

How Cases Were Resolved

Resolution methods included criminal jury trial, civil settlement, guilty pleas, voluntary exclusion from federal health care programs, and corporate integrity agreements.

Health Care Fraud Theories

Fraud cases were based on:

  • products not provided;
  • services not rendered;
  • procedures not medically necessary;
  • bonuses for physicians who ordered unnecessary tests;
  • unlicensed chiropractic clinic services;
  • false billings;
  • kickbacks to patients by waiving the 20 percent Medicare copayment without regard to the patient's financial hardship;
  • excessive and medically unnecessary and inadequately documented peripheral artery interventional services;
  • medications represented to contain pharmaceutical ingredients that did not;
  • bonuses paid to a urologist for referring laboratory tests to a lab;
  • providing a Medicare provider number to a chiropractor who billed Medicare for services rendered;
  • payments to Medicare patients to see physicians who prescribed expensive medications;
  • prescriptions that were "tainted" under the anti-kickback statute because the physician who prescribed them had an alleged ownership interest in the pharmacy that filled them;
  • billing Medicare and TRICARE for rehabilitation therapy services that were not reasonable, necessary, or skilled;
  • administration of misbranded drugs to patients and billing Medicare for them as if they were FDA-approved; and,
  • certain suspect billing practices that when reviewed together indicate an intent to bill for medically unnecessary services.

False Claims Act Cases that Became Federal Criminal Cases

It appears from USAO-MDFL press releases that about five of the matters that started as federal False Claims Act civil cases developed into federal criminal cases. At least one developed after the U.S. Department of Justice (DOJ) evaluated the provider's claim data and concluded the provider was a statistical "outlier." In that case, the USAO-MDFL press release noted that "New and expanded uses of data analytics to identify suspicious billing patterns ... are providing law enforcement with powerful investigative tools ...." Other cases appear to have started as criminal cases without regard to the False Claims Act.

Pointers for USAO-MDFL Health Care Providers

The 24 health care matters mentioned in 2016 USAO-MDFL press releases are of the usual two types. The first type is health care fraud planned from the outset as a fraud. More than half of the 24 matters reviewed appear to involve allegations of such "fraud at the outset." They include providing medically unnecessary services, and Stark law violations. The government may be unable to prove "fraud at the outset" type cases, but with its powerful tools, as long as enough witnesses come forward, and they often do, albeit slowly, it's often easy to prove the fraud with the available documents submitted to Medicare, TRICARE, or another federal health care program.

The second type of health care fraud matter is the more difficult to spot and prosecute business type. In these cases, the health care provider enacts a policy or business practice that ultimately proves unsound and problematic. For example, in the orthopedic surgery practice case the USAO-MDFL recently settled, seven alleged suspect billing practices were involved, all of which appeared to optimize Medicare billings. It's one thing to have one questionable billing practice, but it's another entirely to have seven such practices scrutinized by the MDFL. These become clues. The more clues the USAO-MDFL discovers, the more easily it can make a case, demand a settlement, and impose other conditions.

A few of the 24 matters reviewed could be described as "send a message prosecutions," or national initiatives that result in many simultaneously-filed charges against the same type of alleged violators around the country. The USAO-MDFL and others that enforce the federal statutes realize they can't prosecute all violators, but they can prosecute many and make a lot of noise about it in an effort to deter others from the committing the same violations. These initiatives sometimes stem from published HHS-OIG and DOJ initiatives and priorities.

Claims data submitted to Medicare or its contractor can show if the provider is an outlier, which may prompt an official inquiry by the agencies mentioned above. It's wise to be careful with any "systematic effort to increase ... Medicare and TRICARE billings." Given that individualized health care dominates our health care system, making patients' clinical needs paramount, systematic efforts don't fit well.

Intent is critical in health care fraud as it is in most white collar criminal prosecutions. The USAO-MDFL looks for evidence of bad intent in its health care fraud matters. And it often finds it in emails, text messages, voicemail messages, memos, diaries, notes to self, cheat sheets, and also in the provider's billing practices. It's one thing to inappropriately code and bill for claims "incident" to physician supervision when no physician was present, but when that is combined with a variety of other suspect billing practices, it's easier for the USAO-MDFL to ask hard questions and judge intent.

Compliance programs, which pay for themselves, must be implemented and followed — though they are ineffective in "fraud at the outset" matters. 

The USAO-MDFL's health care fraud and abuse investigations create risk for individuals and companies. It's best to confront the risk when it's detected rather than engage in denial or rationalization. Health care executives must make difficult decisions — e.g., whether to self-report, fight the subpoena, or cooperate. Each decision must contemplate the particular facts uncovered in a defense lawyer's investigation and inquiry into the allegations.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

In association with
Related Video
Up-coming Events Search
Font Size:
Mondaq on Twitter
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
Email Address
Company Name
Confirm Password
Mondaq Topics -- Select your Interests
 Law Performance
 Law Practice
 Media & IT
 Real Estate
 Wealth Mgt
Asia Pacific
European Union
Latin America
Middle East
United States
Worldwide Updates
Check to state you have read and
agree to our Terms and Conditions

Terms & Conditions and Privacy Statement

Mondaq.com (the Website) is owned and managed by Mondaq Ltd and as a user you are granted a non-exclusive, revocable license to access the Website under its terms and conditions of use. Your use of the Website constitutes your agreement to the following terms and conditions of use. Mondaq Ltd may terminate your use of the Website if you are in breach of these terms and conditions or if Mondaq Ltd decides to terminate your license of use for whatever reason.

Use of www.mondaq.com

You may use the Website but are required to register as a user if you wish to read the full text of the content and articles available (the Content). You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these terms & conditions or with the prior written consent of Mondaq Ltd. You may not use electronic or other means to extract details or information about Mondaq.com’s content, users or contributors in order to offer them any services or products which compete directly or indirectly with Mondaq Ltd’s services and products.


Mondaq Ltd and/or its respective suppliers make no representations about the suitability of the information contained in the documents and related graphics published on this server for any purpose. All such documents and related graphics are provided "as is" without warranty of any kind. Mondaq Ltd and/or its respective suppliers hereby disclaim all warranties and conditions with regard to this information, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. In no event shall Mondaq Ltd and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use or performance of information available from this server.

The documents and related graphics published on this server could include technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Mondaq Ltd and/or its respective suppliers may make improvements and/or changes in the product(s) and/or the program(s) described herein at any time.


Mondaq Ltd requires you to register and provide information that personally identifies you, including what sort of information you are interested in, for three primary purposes:

  • To allow you to personalize the Mondaq websites you are visiting.
  • To enable features such as password reminder, newsletter alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our information providers who provide information free for your use.

Mondaq (and its affiliate sites) do not sell or provide your details to third parties other than information providers. The reason we provide our information providers with this information is so that they can measure the response their articles are receiving and provide you with information about their products and services.

If you do not want us to provide your name and email address you may opt out by clicking here .

If you do not wish to receive any future announcements of products and services offered by Mondaq by clicking here .

Information Collection and Use

We require site users to register with Mondaq (and its affiliate sites) to view the free information on the site. We also collect information from our users at several different points on the websites: this is so that we can customise the sites according to individual usage, provide 'session-aware' functionality, and ensure that content is acquired and developed appropriately. This gives us an overall picture of our user profiles, which in turn shows to our Editorial Contributors the type of person they are reaching by posting articles on Mondaq (and its affiliate sites) – meaning more free content for registered users.

We are only able to provide the material on the Mondaq (and its affiliate sites) site free to site visitors because we can pass on information about the pages that users are viewing and the personal information users provide to us (e.g. email addresses) to reputable contributing firms such as law firms who author those pages. We do not sell or rent information to anyone else other than the authors of those pages, who may change from time to time. Should you wish us not to disclose your details to any of these parties, please tick the box above or tick the box marked "Opt out of Registration Information Disclosure" on the Your Profile page. We and our author organisations may only contact you via email or other means if you allow us to do so. Users can opt out of contact when they register on the site, or send an email to unsubscribe@mondaq.com with “no disclosure” in the subject heading

Mondaq News Alerts

In order to receive Mondaq News Alerts, users have to complete a separate registration form. This is a personalised service where users choose regions and topics of interest and we send it only to those users who have requested it. Users can stop receiving these Alerts by going to the Mondaq News Alerts page and deselecting all interest areas. In the same way users can amend their personal preferences to add or remove subject areas.


A cookie is a small text file written to a user’s hard drive that contains an identifying user number. The cookies do not contain any personal information about users. We use the cookie so users do not have to log in every time they use the service and the cookie will automatically expire if you do not visit the Mondaq website (or its affiliate sites) for 12 months. We also use the cookie to personalise a user's experience of the site (for example to show information specific to a user's region). As the Mondaq sites are fully personalised and cookies are essential to its core technology the site will function unpredictably with browsers that do not support cookies - or where cookies are disabled (in these circumstances we advise you to attempt to locate the information you require elsewhere on the web). However if you are concerned about the presence of a Mondaq cookie on your machine you can also choose to expire the cookie immediately (remove it) by selecting the 'Log Off' menu option as the last thing you do when you use the site.

Some of our business partners may use cookies on our site (for example, advertisers). However, we have no access to or control over these cookies and we are not aware of any at present that do so.

Log Files

We use IP addresses to analyse trends, administer the site, track movement, and gather broad demographic information for aggregate use. IP addresses are not linked to personally identifiable information.


This web site contains links to other sites. Please be aware that Mondaq (or its affiliate sites) are not responsible for the privacy practices of such other sites. We encourage our users to be aware when they leave our site and to read the privacy statements of these third party sites. This privacy statement applies solely to information collected by this Web site.

Surveys & Contests

From time-to-time our site requests information from users via surveys or contests. Participation in these surveys or contests is completely voluntary and the user therefore has a choice whether or not to disclose any information requested. Information requested may include contact information (such as name and delivery address), and demographic information (such as postcode, age level). Contact information will be used to notify the winners and award prizes. Survey information will be used for purposes of monitoring or improving the functionality of the site.


If a user elects to use our referral service for informing a friend about our site, we ask them for the friend’s name and email address. Mondaq stores this information and may contact the friend to invite them to register with Mondaq, but they will not be contacted more than once. The friend may contact Mondaq to request the removal of this information from our database.


This website takes every reasonable precaution to protect our users’ information. When users submit sensitive information via the website, your information is protected using firewalls and other security technology. If you have any questions about the security at our website, you can send an email to webmaster@mondaq.com.

Correcting/Updating Personal Information

If a user’s personally identifiable information changes (such as postcode), or if a user no longer desires our service, we will endeavour to provide a way to correct, update or remove that user’s personal data provided to us. This can usually be done at the “Your Profile” page or by sending an email to EditorialAdvisor@mondaq.com.

Notification of Changes

If we decide to change our Terms & Conditions or Privacy Policy, we will post those changes on our site so our users are always aware of what information we collect, how we use it, and under what circumstances, if any, we disclose it. If at any point we decide to use personally identifiable information in a manner different from that stated at the time it was collected, we will notify users by way of an email. Users will have a choice as to whether or not we use their information in this different manner. We will use information in accordance with the privacy policy under which the information was collected.

How to contact Mondaq

You can contact us with comments or queries at enquiries@mondaq.com.

If for some reason you believe Mondaq Ltd. has not adhered to these principles, please notify us by e-mail at problems@mondaq.com and we will use commercially reasonable efforts to determine and correct the problem promptly.