Houston Woman Sentenced for Conspiring to Commit $50 Million Healthcare Fraud and Money Laundering
Knowingly submitting false claims for services not provided or medically unnecessary is considered fraud and violates the False Claims Act.
Compliance Perspective – Medical Testing
Policies/Procedures: The Compliance and Ethics Officer with the Administrator will review policies and procedures involving vendors who provide medical testing to ensure that they have been thoroughly investigated and are not excluded by Medicare and Medicaid.
Training: The Compliance and Ethics Officer and the Director of Nursing will ensure that staff are trained to respond in a timely manner to concerns about medical tests that are ordered and not provided or that are medically unnecessary.
Audit: The Compliance and Ethics Officer should personally conduct an audit to verify that medical tests ordered for residents have been provided and are necessary.
A jury convicted 36-year-old Daniela Gozes-Wagner in September 2017, and recently a U.S. District Judge ordered her to serve 240 months in prison followed by three years of supervised release. She was also ordered to pay restitution of more than $15 million.
Gozes-Wagner began her fraudulent activities in 2009 when she conspired with others to falsely bill Medicare and Medicaid for millions of dollars of medical tests which were either not performed or were medically unnecessary. Over that time, most of the tests were purportedly performed at 28 different testing facilities; however, the investigation discovered that many of the facilities were simply vacant offices.
Gozes-Wagner would hire young women to sit and answer the telephones in the nearly empty facilities. Most of the time these so-called “seat warmers” watched movies, but whenever Medicare investigators tried to inspect the empty offices, the hired “seat warmers” were instructed to notify Gozes-Wagner and to prevent the investigators from making any inspections.
The conspirators substituted the names of other people as the owners of the testing facilities to hide the true identities of the testing facilities’ owners.
