All About the Million-Dollar Medicare Scam Pulled off by Healthsun's Former Executive
Kenia Valle Boza, a former director in the Medicare Risk Adjustment Analytics department at Healthsun Health Plans Inc., orchestrated a Medicare fraud scheme that led to charges amounting to $53 million. Healthsun, established in 2005 with headquarters in Miami, Florida, has emerged as a rapidly growing platform offering medical plans for addressing unexpected medical emergencies. The accused devised a scheme aimed at presenting deceptive CMS (Centers for Medicare & Medicaid Services) information to secure inflated reimbursements from the U.S. Federal Government.
Modus operandi
Boza carried out a scheme to bolster the company's profits and secure personal financial benefits, seemingly underestimating the potential consequences. The Department of Justice intervened, bringing charges against the former executive while absolving Healthsun from direct prosecution. The company found itself entangled in legal troubles, partly attributed to employee negligence and financial motives that not only jeopardized its standing but also tarnished its reputation.
The accused, along with other executives, resorted to presenting falsified documents to the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services. Their objective was to artificially inflate the amount of reimbursement Healthsun received. CMS operates by compensating companies such as Healthsun, dealing in Medicare plans, based on the health conditions of the patients enrolled. Boza submitted fraudulent claims for chronic ailments to CMS, falsely portraying beneficiaries in the company's plans as having conditions that they did not suffer from.
Boza employed unethical means by acquiring login credentials from several physicians, allowing her to unlawfully access Electronic Medical Records (EMR) diagnoses. This unauthorized access was further manipulated by coders when inquiries were made. Along with her co-conspirators, she executed a scheme that involved submitting 10,000 false diagnoses to CMS, leading to substantial payments from the government agency to Healthsun. Besides the Medicare fraud, Boza faces accusations of wire fraud and other serious offenses in the United States, which carry significant prison penalties.
Medicare scams on the rise
The prevalence of Medicare scams shares similarities with financial and banking frauds, wherein scammers often impersonate legitimate entities over the phone. Medicare scammers leverage phone spoofing technology to present themselves as representatives of Medicare companies, altering their numbers and adopting names that mimic health or insurance providers. This deceptive tactic often convinces individuals that they are interacting with a genuine company.
The fraudsters typically follow a pattern, meticulously gathering and storing personal data such as names, addresses, dates of birth, and Social Security numbers (SSNs). Subsequently, they create a sense of urgency, claiming emergencies like an expiring card or enticing individuals with purportedly lower premium plans. Once trust is established, they prompt victims to verify their identity and provide sensitive information, including policy numbers and banking details, ultimately leading to financial scams.
Addressing the issue
This case underscores the necessity of stringent enforcement measures against healthcare fraud. The Medicare scam case serves as a reminder of the ongoing challenges in the healthcare industry, emphasizing the importance of ethical conduct, regulatory oversight, and public awareness in combating fraudulent practices and ensuring the integrity of healthcare systems.