Find Corporate Waste

Tag: Medical Fraud

  • Pennsylvania Medical Supplier Billed $1.3B in Five Months, DOJ Says

    Pennsylvania Medical Supplier Billed $1.3B in Five Months, DOJ Says

    A Pennsylvania medical supplier allegedly submitted $1.3 billion in fraudulent health care claims during a five-month period, according to the Department of Justice⁠.

    Federal prosecutors charged Erekle Gugava, 33, a Georgian national, with conspiring to launder proceeds from the alleged scheme.

    Gugava purportedly owned ND Medical Solutions LLC from February through July 2025. During that period, the durable medical equipment company allegedly billed Medicare, supplemental insurers, employer-sponsored plans and other insurers for equipment that patients never received.

    Insurers paid ND Medical approximately $6.5 million.

    Prosecutors allege the claims relied partly on stolen identities belonging to elderly and disabled Americans. Many beneficiaries reportedly contacted Medicare and its contractors after receiving benefit statements listing equipment they had never requested, doctors they had never visited and a supplier they did not recognize.

    Gugava allegedly opened several ND Medical bank accounts, deposited insurance payments and helped transfer the proceeds to overseas accounts benefiting a transnational criminal organization based in Russia and elsewhere.

  • Complete Health Pays $14.1M Over Inflated Medicare Advantage Diagnoses

    Complete Health Pays $14.1M Over Inflated Medicare Advantage Diagnoses

    Complete Health Partners Holdings will pay $14.1 million to settle allegations that it used unsupported patient diagnoses to increase Medicare Advantage payments.

    The Jacksonville, Florida-based company manages and operates affiliated medical groups in Florida, Alabama and Colorado.

    Under its contracts with Medicare Advantage insurers, Complete Health received a percentage of the payments those insurers collected from the Centers for Medicare & Medicaid Services. Because CMS pays more for patients coded as having serious medical conditions, Complete Health stood to profit when patient risk scores increased.

    According to the Justice Department⁠, Complete Health submitted unsupported diagnoses between 2020 and 2023 involving drug and alcohol dependence, major depression, bipolar disorder and paranoid disorders.

    Federal officials alleged that the company distributed incorrect coding guidance, searched medical records for additional diagnoses and prompted physicians to add conditions that were not clinically justified or properly supported.

    Those diagnoses increased payments from CMS to Medicare Advantage insurers. The insurers then passed part of the additional money to Complete Health.

    The case was brought under the False Claims Act by Karen Bowers, a former associate director of risk adjustment at VIVA Health. Bowers will receive approximately $2.47 million from the federal recovery.

    The settlement shows why insiders remain critical to exposing Medicare Advantage fraud. Employees who understand coding guidance, physician prompts, risk-adjustment reviews and payment arrangements may be able to identify when patient conditions are being exaggerated to extract more taxpayer money.

  • Brooklyn Adult Day Care Owner Gets 57 Months for $3.2M Medicaid Fraud

    Brooklyn Adult Day Care Owner Gets 57 Months for $3.2M Medicaid Fraud

    Brooklyn adult day care owner Eric Zhu surrendered to federal prison to begin serving 57 months for operating a $3.2 million Medicaid fraud and kickback scheme.

    According to the Department of Justice⁠, Zhu, 29, owned Prime Life Adult Day Care LLC.

    From approximately 2020 through 2025, Prime Life paid Medicaid recipients illegal cash kickbacks to enroll in its social adult day care program. The company then billed Medicaid approximately $3.2 million for services those recipients never received.

    Prosecutors said Medicaid paid the fraudulent claims in full. Zhu used multiple business entities to launder the proceeds and generate cash for the kickbacks. Investigators recovered some of that cash during a search of Prime Life.

    Zhu was ordered to pay nearly $3.2 million in restitution and forfeit another $1.5 million in fraud proceeds.

  • SSM Health Pays Nearly $1M After Pharmacy Copay Waiver Allegations

    SSM Health Pays Nearly $1M After Pharmacy Copay Waiver Allegations

    This case is an example of how the Trump Administration’s Department of Justice is clawing back billions of taxpayer dollars from fraud schemes throughout the country.

    The United States has reached a $939,290 civil settlement⁠ with SSM Health Care over allegations that the retail pharmacy at Saint Louis University Hospital routinely waived patient copays, causing Medicare and the Federal Employees Health Benefits Program to overpay for prescriptions.  

    DOJ says the conduct ran from September 2020 through February 2023, with pharmacy employees allegedly waiving or failing to collect copays. That is not a harmless discount. Routine copay waivers can steer patients to one pharmacy, hide the real prescription cost, and inflate what federal programs pay.

    The case began with a qui tam whistleblower suit filed under the False Claims Act. The whistleblower will receive $159,210, while SSM will also pay $150,000 in fees and costs. SSM did not admit liability and DOJ credited the company’s cooperation and remedial action.  

    For FCW, the takeaway is direct: when providers manipulate the economics behind federally reimbursed claims, the taxpayer is left holding the bill. Copays are not paperwork. They are part of the program-integrity firewall.

  • Circle Medical to Pay $3.325M Over Alleged False Healthcare Claims

    Circle Medical to Pay $3.325M Over Alleged False Healthcare Claims

    San Francisco-based Circle Medical Care of California, Circle Medical Technologies, Inc., and Chief Medical Officer Dr. Nicole Tsang, D.O., agreed to pay $3,325,000 to resolve allegations that they submitted false claims to federal healthcare programs and California commercial insurers.

    According to the DOJ⁠, Circle operates an online telehealth platform offering mental health and primary care services through contract providers, including nurse practitioners and physician assistants. The government alleged that from January 1, 2018 through May 31, 2025, Circle submitted claims using the names and NPI numbers of rendering providers who did not actually provide or supervise the services billed. The claims allegedly involved programs including Medicare, Medicaid, and TRICARE.  

    The settlement allocates $475,000 to the United States and $2.85 million to California. The matter began as a qui tam whistleblower case filed by Jason Vellen, who will receive $80,750 from the federal recovery and $997,500 from California.  

    This case fits the broader Find Corporate Waste focus on healthcare payment integrity: claims data, provider identifiers, supervision rules, and federal program billing requirements can expose recoverable taxpayer losses. 

  • Ahold Delhaize USA to Pay $40M Over Allegedly Inflated Pharmacy Prices

    Ahold Delhaize USA to Pay $40M Over Allegedly Inflated Pharmacy Prices

    Ahold Delhaize USA Inc.⁠, the parent company behind supermarket pharmacy brands including Giant, Hannaford, Stop & Shop, Food Lion, and others, has agreed to pay $40 million to resolve False Claims Act allegations involving prescription drug pricing.

    According to the DOJ⁠, Ahold Delhaize allegedly reported inflated “usual and customary” prices on claims submitted to Medicare Part D, Medicaid, and TRICARE. Prosecutors said the company operated prescription savings programs that offered discounted prices to enrolled customers, but allegedly failed to report those discounted prices as the pharmacies’ usual and customary prices.

    That distinction matters because usual and customary prices can operate as ceiling prices in federal health care reimbursement formulas. The government alleged that by reporting higher prices, Ahold Delhaize caused federal health care programs to pay more than they should have paid on pharmacy claims.

    Of the $40 million settlement, $32.9 million represents the federal share, with the remainder going to participating states.

    The case began as a whistleblower action filed by Lawrence LaBenne, a Pennsylvania pharmacist at an Ahold Delhaize supermarket.

    He will receive $6,083,587 from the federal recovery.

    The settlement is another example of how pricing representations, claim-level billing data, and insider knowledge drive many False Claims Act recoveries.

    For Find Corporate Waste⁠, the case fits the broader enforcement pattern: federal programs rely on accurate certifications and truthful claim data, and public money can be recovered when those representations are allegedly false.

  • $56.5M Settlement Targets Medicare Diagnosis Codes Scheme

    $56.5M Settlement Targets Medicare Diagnosis Codes Scheme

    Community Care Health Network LLC, doing business as Matrix Medical Network, DPN USA, doing business as HealthFair, and Shahriah “James” Ekbatani agreed to pay $56.5 million to resolve False Claims Act allegations over unsupported Medicare Advantage diagnosis codes, the DOJ announced.

    Matrix will pay $36.5 million, HealthFair will pay $5 million, and Ekbatani will pay $15 million.

    The DOJ alleged the defendants caused Medicare Advantage Organizations to submit false or invalid diagnosis codes to CMS, increasing risk-adjusted taxpayer payments.

    Matrix allegedly used in-home assessments to report unsupported conditions. HealthFair allegedly used mobile assessment buses to report unsupported diagnoses under Ekbatani’s direction.

    The whistleblowers will receive major awards. Former Matrix employee Nancy Cahill will receive $7.3 million. Former HealthFair chief medical officer Dr. Robert Oristaglio Jr. will receive $3.6 million.

    Insiders with knowledge of unsupported diagnosis coding, chart-review pressure, mobile assessments, or Medicare Advantage billing failures may have information relevant to public-fraud enforcement.

    Find Corporate Waste helps protect insiders while exposing fraud, waste, and abuse in taxpayer-funded programs.

  • Oglethorpe Pays $32M Over Medicare Overpayment Allegations

    Oglethorpe Pays $32M Over Medicare Overpayment Allegations

    Oglethorpe Inc. and three top executives agreed to pay $32 million to resolve False Claims Act allegations tied to Medicare overpayments at behavioral health facilities.

    According to the DOJ, Oglethorpe, its founder Robert Cohen, CEO John Picciano, and COO James O’Shea allegedly failed to return overpayments that the company’s own consultants had identified.

    The alleged overpayments involved Medicare beneficiaries admitted to Ridgeview Behavioral Hospital, Georgetown Behavioral Hospital, and The Woods at Parkside, despite allegedly not qualifying for inpatient psychiatric care.

    The case stands out because Oglethorpe had already entered a 2021 Corporate Integrity Agreement after an earlier FCA settlement. Following alleged violations, the defendants agreed to a 10-year exclusion from Medicare, Medicaid, and all federal health care programs beginning in July 2026.

    The lawsuit was filed by four former Oglethorpe employees under the FCA’s whistleblower provisions. Their relator share has not yet been determined.

  • Brooklyn Clinic Owner Convicted in $52M Health Care Fraud and Kickback Scheme

    Brooklyn Clinic Owner Convicted in $52M Health Care Fraud and Kickback Scheme

    A federal jury in the Eastern District of New York convicted Tony Brown-Arkah, 78, owner of American Medical Centers, a Brooklyn clinic that purported to provide substance abuse treatment, for his role in a $52 million health care fraud, narcotics, and kickback scheme.

    According to the Department of Justice, Brown-Arkah’s clinic illegally prescribed Suboxone, a Schedule III narcotic used to treat opioid use disorder, while allowing drug diversion activity to operate around the clinic. Witnesses testified that patients were directed to sell prescriptions outside the facility, including to a van near the clinic.

    The DOJ said many patients received prescriptions signed by a nurse practitioner in Florida who did not see or speak with them. Patients were also subjected to medically unnecessary testing, while Medicare and Medicaid were billed for services that were not provided or not legitimate.

    Brown-Arkah was also convicted of paying patient kickbacks and receiving laboratory kickbacks tied to unnecessary testing referrals. Prosecutors said he used a shell company and sham contract to conceal the payments.

    The case reflects the DOJ’s continued focus on health care fraud involving addiction treatment, laboratory testing, controlled substances, and federal program billing.

    DOJ Press Release — Clinic Owner Convicted for $52M Health Care Fraud, Illegal Narcotics Distribution, and Kickback Scheme

    DOJ Health Care Fraud Unit

    Find Corporate Waste — False Claims Act

  • Minnesota Medicaid Fraud Takedown Charges 15 Defendants in Alleged $90M Scheme

    Minnesota Medicaid Fraud Takedown Charges 15 Defendants in Alleged $90M Scheme

    The DOJ announced a major Minnesota health care fraud takedown on May 21, 2026, charging 15 defendants in alleged schemes involving more than $90 million in intended loss.

    The charges target owners of child care centers, autism-service providers, housing-support operators, and other Medicaid-linked providers accused of exploiting public programs designed for vulnerable children, disabled adults, seniors, and low-income families.

    According to the DOJ, the largest case involves Minnesota’s Early Intensive Developmental and Behavioral Intervention program, known as EIDBI, which provides services for people under 21 with autism spectrum disorder.

    Two defendants were charged in connection with an alleged $46.6 million scheme involving kickbacks to parents, medically unnecessary autism diagnoses, and billing for autism services that were not actually provided.

    The growth of the program is staggering. The DOJ said EIDBI claims rose from more than $600,000 in 2018 to more than $400 million by 2025. That kind of explosion is exactly why health care fraud enforcement increasingly depends on data analytics, billing-pattern review, and cross-agency scrutiny.

    The takedown also includes first-of-their-kind criminal prosecutions involving Minnesota’s Integrated Community Supports and Individualized Home Supports programs. In the ICS case, prosecutors allege a defendant billed Medicaid for services that were not provided as represented, including for a vulnerable recipient who required 24-hour care and was later found deceased. In the IHS case, two defendants allegedly concealed financial interests in more than 20 residences while billing Medicaid for services tied to adults with disabilities.

    The DOJ also charged eight defendants in alleged Housing Stabilization Services fraud totaling approximately $15.7 million. That program was created to help people with disabilities, seniors, and people with mental health or substance-use disorders find and maintain housing. But prosecutors said low barriers to entry and minimal documentation requirements made the program vulnerable to fraud. Minnesota eventually shuttered the program on October 31, 2025, after fraud concerns overwhelmed its integrity.

    This announcement is not just about Minnesota. The DOJ also announced funding for 15 new Trial Attorney positions to expand Medicaid fraud enforcement nationwide. The department said these prosecutors will support existing strike forces in states including California, Florida, New York, and Texas, while also expanding rapid-response enforcement across the country.

    For Find Corporate Waste, the message is clear: Medicaid fraud is not a paperwork problem. It is a taxpayer-integrity problem. These programs exist to serve people with serious needs, but weak controls, loose provider entry standards, shell-provider structures, and explosive billing growth can turn public benefits into private revenue machines.

    The DOJ also emphasized that its Health Care Fraud Section’s Data Fusion Center used advanced data analytics to identify and support the Minnesota cases. That matters. Public records, provider data, corporate filings, exclusion lists, addresses, ownership patterns, billing spikes, and program-growth anomalies can reveal serious fraud signals long before a prosecution is announced.

    This is the kind of enforcement environment where public-interest data mining matters. Find Corporate Waste tracks fraud, waste, abuse, and False Claims Act enforcement because taxpayers deserve to know how public money is being spent, who is exploiting weak oversight, and our country will not survive the looting of our government for personal gain.