Founded in 1965 under the Social Security Administration, Medicare is our nation’s health insurance program. Now administered by the Centers for Medicare and Medicaid Services (CMS), Medicare provides health insurance for more than 57 million Americans who are over the age of 65. It also insures about 8 million individuals of all ages who have disabilities.
It should go without saying that Medicare is a vitally important part of the fabric of our country. Sadly, as the Allegiant Experts Blog has highlighted quite often in the past, the health insurance program is also the constant victim of fraud. This is evidenced by the recent guilty plea of Dr. Victor Contreras. The 68 year-old Santa Paula, California resident pleaded guilty to defrauding Medicare out of more than $3 million.
Contreras billed Medicare for medically unnecessary hospice services.
Last week, the Central District of California branch of the U.S. Attorney’s Office made the announcement about the doctor’s guilty plea. According to the report, Contreras worked for two Pasadena-based hospices: Arcadia Hospice Provider Inc., and Saint Mariam Hospice Inc. In his plea agreement, he admitted to working with a co-conspirator who controlled both companies.
The co-conspirator was 61 year-old, Juanita Antenor. The former Pasadena resident worked with Contreras in a health care fraud scheme lasting between July of 2016 and February of 2019. Together, they submitted upwards of $4 million worth of false and fraudulent claims for hospice services. The claims were submitted by the two hospice companies.
Medicare only covers hospice services for patients who are terminally ill.
A terminally ill individual is defined by someone who has a life expectancy of six months or less if their illness has run its normal course. According to the U.S. Attorney’s Office, Contreras falsely stated on claims forms that his patients had terminal illnesses. This, of course, would make them eligible for hospice services covered by Medicare. He typically adopted diagnoses provided to him by hospice employees whether they were true or not.
“Contreras did so even though he was not the patients’ primary care physician and had not spoken to those primary care physicians about the patients’ conditions,” the report details, “Medicare paid on the claims supported by Contreras’ false evaluations and certifications and recertifications of patients. In total, approximately $3,917,946 in fraudulently claims were submitted to Medicare, of which a total of approximately $3,289,889 was paid.”
Antenor remains at large.
While Contreras has pleaded guilty to his crimes, his main co-conspirator has not yet been brought to justice. Another co-conspirator, Callie Black has pleaded not guilty. The 65 year-old Lancaster, California resident is alleged to have recruited patients for the hospice companies in exchange for illegal kickbacks. Black’s trial is scheduled to begin on October 15, 2024.
Meanwhile, a sentencing hearing for Contreras is set for October 25. He faces a statutory maximum sentence of 10 years in federal prison.
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