Clinics allegedly sought reimbursement for injection treatments, physical therapy treatments and other medical items and services not ordered by doctors.
Four company owners and 14 others have been indicted in Miami-Dade County for their alleged participation in private insurance healthcare fraud resulting in over $125 million in false and fraudulent claims to be submitted and $13 million to be paid, according to the U.S. Attorney Southern District of Florida.
Claims were submitted to Cigna, Blue Cross Blue Shield, United Health Care and Administrative Services Only plans managed by Cigna, BCBS, and UHC, on behalf of the medical clinics seeking approximately $125 million in reimbursement for injection treatments, physical therapy treatments and other medical items and services. The treatments were neither ordered by a physician nor provided to a beneficiary as claimed, according to the indictment.
Based on these false and fraudulent claims, Cigna, BCBS and UHC, as well as, ASO insurance plans managed by Cigna, BCBS and UHC, paid the medical clinics approximately $13 million, it said.
Defendants Reynaldo Castillo, 46, Hendris Castillo Morales, 33, Lisbet Castillo Batista, 23 and Maite Garcia, 40, owned and controlled 30 companies based in Miami, Hialeah, Hialeah Lakes, and Doral, Florida, according to the indictment.
Reynaldo Castillo, Lisbet Castillo Batista, and Hendris Castillo incorporated Investors Group of Florida Corp. to receive proceeds from the medical clinics and used those proceeds to purchase real estate properties, it stated. Investors Group of Florida Corp., with Reynaldo Castillo as president and registered agent, was listed as owner of the purchased real estate properties and acted as the leasing agent, according to the U.S. Attorney’s Office.
The real properties are subject to criminal forfeiture as specified in the indictment.
The defendants used medical director staffing companies to obtain and misappropriate the names and licensing information for numerous physicians to submit the fraudulent claims, the indictment stated.
Companies and organizations affected by the alleged fraud, according to the U.S. Attorney’s Office, include Cigna, Blue Cross Blue Shield, United Health Care, Miami-Dade County Public Schools, City of Miami, Pepsi Co., BJ’s Wholesale Club, Inc., Lincoln Property Company, Macy’s Inc., Nextera Energy Inc., Radioshack Corporation, Sodexo, Inc., Southeast Frozen Foods Company LP, and other self-insured employers which offered ASO insurance plans to their employees.
ASO insurance plans reimbursed Cigna, BCBS, and UHS for the money paid out by the insurance companies for health benefits for their respective employees. Therefore, the employers acted in a self-insured role; making them financially responsible for any claim payments to their employees, according to the U.S. Attorney’s Office.
Castillo, and the conspirators were charged with conspiracy to commit healthcare fraud and health care fraud. In addition, Garcia was charged for her alleged role in paying kickbacks and bribes to certain beneficiaries in order to reimburse the beneficiaries for their monthly premium payments to Cigna.
The indictment further alleges that Alejandro Biart, 40, accepted kickbacks from co-conspirators in return for referring Cigna, BCBS, and UHC beneficiaries to the medical clinics controlled by Reynaldo Castillo, Hendris Castillo Morales, Lisbet Castillo Batista, and Maite Garcia.
According to the indictment, 11 other individuals agreed, in exchange for a fee, to have companies placed in their names, to open bank accounts and check cashing accounts in the names of the companies, and to cash and deposit checks received from Cigna, BCBS, and UHC.
The indictment alleges that Ernesto Castillo, 43, Osvaldo Marin Medina, 48, Alejandro Biart, 40, Danny Jacomino Bordon, 50, and their co-conspirators submitted and caused Amazing Medical Services Inc. to submit claims to Cigna seeking reimbursement of over $1 million, which claims falsely and fraudulently represented that medical services were prescribed by a doctor and provided to Cigna beneficiaries by Amazing. As a result of such false and fraudulent claims, Cigna made payments to Amazing totaling $86,035, according to the indictment.
The indictment further alleges that Ernesto Castillo, Osvaldo Marin Medina and Alejandro Biart caused Serenity Rehabilitation Center, Inc. to submit fraudulent claims to Cigna seeking reimbursement of over $1.8 million, which resulted in $252,259 in reimbursement payments to Serenity.
The defendants also caused World of Rehabilitation Therapy to submit fraudulent claims to Cigna seeking reimbursement of over $2 million, which resulted in $889,151 in payments to World of Rehab from Cigna.