Mary Talaga, a 54-year old woman from Elmwood Park, Illinois, ran a five-year health care scheme in which she and co-conspirators defrauded Medicare for $4 million.
A medical biller is the person who reviews hospital and patient records, determines charges, examines and submits claims, and manages payments. Talaga was the primary medical biller at Medicall Physicians Group Ltd. The Chicago-area visiting physician practice had doctors visit patients in their home and prescribe and oversee home health care.
A five-year scheme
Evidence presented in trial showed that Talaga routinely billed Medicare for services Medicall did not actually provide, such as services to deceased patients and services they claim were provided by physicians who no longer worked for Medicall. Inaccurate billing records reported physicians working over 24 hours per day, and showed Medicall providing “care plan oversight” that they did not actually provide.
During the five-year conspiracy, Talaga submitted claims for $4 million in medical services that were not provided, of which Medicare paid $1 million.
Talaga was convicted in May 2015 of one count of conspiracy to commit healthcare fraud, six counts of healthcare fraud, and three counts of false statements relating to healthcare. She will spend 45 months in prison, and pay $1 million in restitution.
Medicall’s medical director, Roger Lucero, and one other man were both convicted of participating in the scheme and will serve prison sentences. Lucero has pled guilty and will receive his sentence in the future. The other man, Rick Brown, was sentenced to over 7 years in prison.
Stopping fraud
The Medicare Fraud Strike Force was involved in bringing this case to the attention of the Criminal Division’s Fraud Section. The FBI and HHS-OIG (Department of Health and Human Services, Office of Inspector General) together ran the investigation, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office of the Northern District of Illinois.
Medicare fraud costs the government (and thus, taxpayers) billions of dollars a year. But the U.S. government has gotten serious about stopping fraud, creating task forces to find and convict those who abuse the system. The Medicare Fraud Strike Force has charged 2,300 defendants who, all together, have billed Medicare for over $7 billion. The Health Care Fraud Prevention and Enforcement Action Team (HEAT), created by HHS in 2009, cracks down on fraudsters to help prevent the loss of billions of dollars a year.
This year, HEAT led the largest medical fraud take-down in U.S. history, involving $712 million in fraudulent billing.
To learn more about HEAT, visit www.stopmedicarefraud.gov.
For more information/questions regarding any legal matters, please email [email protected] or call 310.203.2800.