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United States v. Willner

United States District Court, S.D. Florida

February 14, 2011

UNITED STATES OF AMERICA
v.
MARK WILLNER, MD, ALAN GUMER, MD, ALBERTO AYALA, MD, VANJA ABREU, Ph.D, NANCY MERCED-SOLA, LYDIA WARD, Ph.D, NICHOLE ECKERT, SANDRA JIMENEZ a/k/a Sabrina Jimenez, HILARIO MORRIS a/k/a Larry Morris, JOSEPH VALDES a/k/a Joseph Valdez, ADRIAN MEJIA, PEDRO SOSA, YOISEL CANCIO, MATHIS MOORE, NELSON FERNANDEZ, LEYANES PLACERES, JAMES EDWARDS, FRANK CRIADO, and CURTIS GATES, Defendants. Count Defendant(s) Beneficiary Name Services Billed Approx. Claim Receipt Date Amount Billed Claim Number Count Defendant Monetary Transaction Approx. Date Count Defendant(s) Financial Transaction Approx. Date

         18 U.S.C. § 1349, 18 U.S.C. § 1347, 18 U.S.C. § 371, 18 U.S.C. § 1956(h), 18 U.S.C. § 1957, 18 U.S.C. § 1956(a), 31 U.S.C. § 5324(a), (d), 18 U.S.C. § 2, 18 U.S.C. § 982

          WIFREDO A. FERRER UNITED STATES ATTORNEY SOUTHERN DISTRICT OF FLORIDA

          HANK K BOND WALTHER DEPUTY CHIEF CRIMINAL DIVISION, FRAUD SECTION U.S. DEPARTMENT OF JUSTICE

          JENNIFER L. SAULINO MARIA GONZALEZ CALVET TRIAL ATTORNEYS CRIMINAL DIVISION, FRAUD SECTION U.S. DEPARTMENT OF JUSTICE

          ORDER

         INDICTMENT

         The Grand Jury charges that:

         GENERAL ALLEGATIONS

         At all times relevant to this Indictment, 1. The Medicare Program ("Medicare") is a federal health care program providing benefits to persons who were over the age of sixty-five or disabled. Medicare is administered by the Centers for Medicare and Medicaid Services ("CMS"), a federal agency under the United Stales Department of Health and Human Services. Individuals who receive benefits under Medicare are referred to as Medicare "beneficiaries." Medicare is a "health care benefit program, " as defined by Title 18, United States Code, Section 24(b).

         2. Part B of the Medicare program covers partial hospitalization programs ("PHPs") connected with the treatment of mental illness. The treatment program of PHPs closely resembles that of a highly structured, short-term hospital inpatient program, but it is a distinct and organized intensive treatment program that offers less than 24-hour daily care and is designed, in part, to reduce medical costs by treating qualifying individuals outside the hospital setting.

         3. Under the PHP benefit. Medicare covers the following services: (1) individual and group therapy with physicians or psychologists (or other authorized mental health professionals); (2) occupational therapy; (3) services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients; (4) drugs and biologicals furnished for therapeutic purposes that cannot be self-administered; (5) individualized activity therapies that are not primarily recreational or diversionary; (6) family counseling (for treatment of the patient's condition); (7) patient training and education; and (8) diagnostic services.

         4. Medicare generally requires that the PUP be provided at a facility that is hospital-based or hospital-affiliated, but Medicare also allows a PHP to be provided in a Community Mental Health Center ("CMHC"), which is a provider type under Part A of Medicare.

         5. Medicare requires that, to qualify for the PHP benefit, the services must be reasonable and necessary for the diagnosis and active treatment of the individual's condition. The program also must be reasonably expected to improve or maintain the condition and functional level of the patient and to prevent relapse or hospitalization. The program must be prescribed by a physician and furnished under the general supervision of a physician and under an established plan of treatment that meets Medicare requirements.

         6. Typically, a patient who needs this intensive PHP treatment has a long history of mental illness that has been treated. Patients are ordinarily referred either (a) by a hospital after Ml inpatient hospitalization for severe mental illness or (b) by a doctor who is trying to prevent full inpatient hospitalization for a severely mentally ill patient the doctor has been treating.

         7. Medicare guidelines specifically exclude meals and transportation from coverage under the PHP benefit.

         8. Medicare does not cover programs involving primarily social, recreational, or diversionary activities.

         9. In order to receive payment from Medicare, a CMHC, medical clinic or physician is required to submit a health insurance claim form to Medicare, called a Form 1450. The claims may be submitted in hard copy or electronically. A CMHC, medical clinic, and physician may contract with a billing company to transmit claims to Medicare on their behalf.

         10. Part B of the Medicare program also covers diagnostic sleep studies conducted at sleep disorder clinics. Medicare covers all reasonable and necessary diagnostic tests given for certain medical conditions when the clinic is affiliated with a hospital or is under direction and control of physicians; when patients are referred to the sleep disorder clinic by their attending physicians and the clinic maintains a record of the attending physician's orders; and the need for diagnostic testing is confirmed by medical evidence such as physician examinations and laboratory tests. In particular, Medicare pays for sleep studies if the patient has symptoms or complaints of one of the following conditions, and only under certain limited circumstances: narcolepsy, sleep apnea, impotence, and parasomnia. Chronic insomnia is not covered.

         11. In order to receive payment from Medicare, a sleep disorder clinic is required to submit a health insurance claim form to Medicare, called a Form 1500. The claims may be submitted in hard copy or electronically. A sleep disorder clinic may contract with a billing company to transmit claims to Medicare on their behalf.

         12. Medicare Part B is administered in Florida by First Coast Service Options ("FCSO"), which, pursuant to contract with the United States Department of Health and Human Services, serves as a contracted carrier to receive, adjudicate and pay Medicare Part B claims submitted to it by Medicare beneficiaries, physicians, or CMHCs. Medicare Part B pays CMHCs and physicians directly for the cost of PHP services furnished to eligible Medicare beneficiaries, provided that the services meet Medicare requirements.

         Defendants, Relevant Entities, and Relevant Persons

         13. American Therapeutic Corporation ("ATC") was a Florida corporation originally established in 2002 and was headquartered in Miami, Florida, ATC operated several purported PHPs throughout Florida from Homestead to Orlando, including PHPs at the following addresses: 1801 NE 2"" Avenue, Miami, Florida 33132; 61 Grand Canal Drive, Suite #100, Miami, Florida 33144; 1001 West Commercial Blvd., Fort Lauderdale, Florida 33309; 4960 North Dixie Highway, Fort Lauderdale, Florida 33334; 27112 South Dixie Highway, Naranja, Florida 33032; 717 East Palmetto Park Road, Boca Raton, Florida 33432; and 4790 North Orange Blossom Trail, Orlando, Florida 32810.

         14. Medlink Professional Management Group, Inc. ("Medlink") was a Florida corporation established in 2003 and was headquartered at 484 Brickell Avenue, Suite 1220, Miami, Florida 33132 and later at 1809 NE 2nd Avenue, Miami, Florida 33132. Medlink was used to charge monthly fees to ATC for managing ATC's operations, including hiring employees, running daily operations, and controlling finances and other site management activities.

         15. The American Sleep Institute ("ASI") was a Florida corporation established in 2005 and was headquartered in Miami, Florida at the offices of Medlink. ASI was later headquartered in Hialeah, Florida. ASI purportedly provided sleep study services.

         16. Defendants MARK WILLNER, MD, a resident of Miami-Dade County, ALAN GUMER, MD, a resident of Broward County, and ALBERTO AYALA, MD, a resident of Miami-Dade County, were physicians licensed in the State of Florida and were medical directors at ATC and referring physicians to ASI.

         17. Defendants VANJA ABREU, Ph.D, a resident of Broward County, NANCY MERCED-SOLA, a resident of Orange County, and LYDIA WARD, Ph.D, a resident of Miami-Dade County, were "program directors" at ATC.

         18. Defendant NICHOLE ECKERT, a resident of Miami-Dade County, was a therapist at ATC.

         19. Defendants SANDRA JIMENEZ, a/k/a Sabrina Jimenez, and HILARIO MORRIS, a/k/a Larry Morris, residents of Miami-Dade County, and JOSEPH VALDES, a/k/a Joseph Valdez, a resident of Broward County, were "marketers" for ATC who would pay and cause the payment of kickbacks in exchange for Medicare beneficiaries to attend ATC and ASI.

         20. Defendant ADRIANA MEJIA, a resident of Miami-Dade County, cashed checks for MEDLEVK and was the owner of multiple companies used to conceal the illicit conversion of checks into cash. Those companies included Andorra Printer Designs, Computer Resources Management Review Company, Pulp & Paper Company, Stamina Company, and FKEE OF DIRT.COM.

         21. Defendant _____ resident of Miami-Dade County, cashed checks for MEDLINK and was a co-owner of _____ used by himself and others to conceal the illicit conversion of checks into cash, 22. Defendants PEDRO SOSA, a resident of Miami-Dade County, and YOISEL CANCIO, a resident of Miami-Dade County, cashed checks for MEDLINK and used companies such _____ to conceal the illicit conversion of checks into cash.

         23. Defendants MATHIS MOORE, NELSON FERNANDEZ, and LEYANES PLACERES, residents of Miami-Dade County, JAMES EDWARDS, a resident of Broward County, FRANK CRIADO, a resident of Miami-Dade County, and CURTIS GATES, a resident of Broward County, were patient brokers who worked with ATC, ASI, and Medlink to funnel ineligible patients into their PHP programs and sleep studies in exchange for kickbacks.

         24. Lawrence S. Duran, a resident of Miami-Dade County, was the manager and owner of ATC and Medlink. Duran was also the registered agent for ASI.

         25. Marianella Valera, a resident of Miami-Dade County, was the owner, CEO, president, secretary and treasurer of ATC. Valera was also the vice president of ASI.

         26. Judith Negron, a resident of Miami-Dade County, was the vice president and part owner of Medlink and owner and president of ASI.

         27. Margarita Acevedo, a/k/a Margarita De La Cruz, a resident of Miami-Dade County, was the Marketing Director of ATC. Acevedo supervised ATC's marketers but worked for Medlink.

         COUNT 1

         Conspiracy to Commit Health Care Fraud (18 U.S.C. § 1349)

         1. Paragraphs 1 through 19 and 23 through 27 of the General Allegations section of this Indictment are realleged and incorporated by reference as though fully set forth herein.

         2. From on or about December 13, 2002, through on or about October 21, 2010, in Miami-Dade County, in the Southern District of Florida, and elsewhere, the defendants,

MARK WILLNER, MD,
ALAN GUMER, MD, ALBERTO AYALA, MD,
VANJA ABREU, Ph.D,
NANCY MERCED-SOLA,
LYDIA WARD, Ph.D,
NICHOLE ECKERT,
SANDRA JIMENEZ a/k/a Sabrina Jimenez,
HILARIO MORRIS a/k/a Larry Morris,
JOSEPH VALDES a/k/a Joseph Valdez,
MATHIS MOORE,
NELSON FERNANDEZ,
LEYANES ...

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