2010 Award Winners

Investigation of the Year
Investigation of the Year: Honorable Mention
Excellence in Public Awareness
Investigative Excellence Award
Medical Director

Investigation of the Year

United States of America v. Stephen J. Schneider, D.O and Linda K. Schneider, L.P.N.

Presented to

United States Department of Justice, United States Attorney's Office
District of Kansas

United States Department of Health and Human Services, Office of Inspector General
Kansas City Regional Office

United States Department of Justice, Federal Bureau of Investigation
Kansas City Division

United States Department of Justice, Drug Enforcement Administration
Kansas City District Office

United States Postal Inspection Service
Wichita Field Office

Kansas Office of the Attorney General
Medicaid Fraud and Abuse Division

Kansas Bureau of Investigation

Preferred Health Systems

BlueCross BlueShield of Kansas

IntegriGuard, L.L.C. (Medicare)

HP Enterprise Services (Kansas Medical Assistance Program/Medicaid)

A four-year investigation into the operation of a pain management clinic in a small community south of Wichita, Kansas, uncovered evidence of extensive over-prescribing of controlled substances. More than 100 drug overdoses requiring visits to area emergency rooms and the deaths of at least 68 persons are linked to this case. A 34-count indictment charged the husband and wife defendants with health care fraud resulting in death, unlawfully dispensing controlled substances resulting in death, and money laundering. After an eight-week trial, the defendants were convicted and sentenced to prison-30 years for the physician husband and 33 years for his nurse wife-well exceeding the minimum 20-year sentence. The jury found that the couple directly contributed to the deaths of 10 patients. In summing up the case, the presiding federal judge called it "an avoidable tragedy motivated by greed."

Congratulations to

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AUSA Tanya J. Treadway
AUSA Jon P. Fleenor
AUSA Alan G. Metzger
AUSA Annette B. Gurney
SAUSA Jabari Wamble
Litigation Support Specialist Pauletta Boyd
Paralegal Sean Moore
Legal Assistant Patti Korwin
Legal Assistant Angie Bramhall
USAO District of Kansas

Senior Special Agent William V. Roland
Kansas Bureau of Investigation

Investigator C. Martin Redd
U.S. Department of Justice, Drug Enforcement Administration

S.I.U. Investigator Jaime Leyden
Preferred Health Systems

Medical Review Nurse Jaime Dahlberg, RN, BSN
SURS Senior Investigator Heidi Haney, CFE
IntegriGuard, L.L.C.(Medicare)

Special Agent James D. Greer
Special Agent Andrew G. Stewart
Senior Program Analyst Perry A. Seaton
Department of Health and Human Services OIG

Special Agent Rebecca L. Martin
Asset Forfeiture Investigator Emilee Thompson
Federal Bureau of Investigation, Kansas City Division

Inspector Barry L. Rausch
U.S. Postal Inspection Service

S.I.U. Auditor Marguerite Mzhickteno
BlueCross Blue Shield of Kansas

Supervisor Tracy W. Wagner, RN, BSN
HP Enterprise Services, Kansas Medical Assistance Program (Medicaid)

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2010 Investigation of the Year: Honorable Mention

United States of America v. Michel De Jesus Huarte et al.

Presented to

United States Department of Justice
United States Attorney's Office, Southern District of Florida

United States Department of Justice, Federal Bureau of Investigation
Miami Division
Atlanta Division

United States Department of Health and Human Services
Office of Inspector General , Office of Investigations
Savannah Field Office
Jacksonville Field Office

Department of the Treasury, Internal Revenue Service
Criminal Investigation-Miami

Florida Department of Law Enforcement
Broward County Sheriff's Office
Aetna
Humana
WellPoint
Coventry Health Care
BlueCross BlueShield of Florida
Universal American Corp.
Sterling Health Care Plans

Congratulations to

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AUSA Ryan Stumphauzer
AUSA Daniel Bernstein
United States Attorney's Office, Southern District of Florida

Special Agent David Graupner
Special Agent Kelly A. McCoy
U.S. Department of Health and Human Services, Office of Inspector General-Investigations
Savannah Field Office
Jacksonville Field Office

Special Agent Christopher Vastine
Special Agent Larry Masterson
Florida Department of Law Enforcement

Craig A. Bodway
V.P., Compliance and Regulatory Affairs
Sterling Health Care Plans

Susan Kennedy, SIU Team Leader
Robert J. Maher, Sr. Investigator
Aetna

Danielle Van De Hey
Manager of Special Investigations
Humana

Maria E. Diaz, Senior Investigator
BlueCross BlueShield of Florida

Special Agent Liz S. Santamaria
Special Agent Avatar LeFevre
Special Agent Susan E. Shimpeno
Special Agent Christopher A. Macrae
Special Agent William E. Share
Financial Analyst Andrea C. Blencowe
Federal Bureau of Investigation

Special Agent Lydia Chabrier
Department of the Treasury, Internal Revenue Service
Criminal Investigation-Miami

Detective Steven Sinatra
Detective Brian Dietrick
Broward County Sheriff's Office

Investigator Jayne Cabaliw
Investigator LaTanya D. Johnson
Universal American Corp.

Michael A. Paluselli, SIU Manager
Coventry Health Care

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2010 Excellence in Public Awareness

Presented to

Senior Medicare Patrol Program, Administration on Aging
United States Department of Health & Human Services

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The National Health Care Anti-Fraud Association is proud to name the Senior Medicare Patrol Program as the recipient of the 2010 NHCAA Excellence in Public Awareness Award. This award is bestowed annually upon an organization or individuals who have done the most in the past year to raise public awareness about the problem of health care fraud in our nation's health care system.

Senior Medicare Patrol (SMP) is a program of the Administration on Aging, itself an agency within the U.S. Department of Health & Human Services. SMP is being recognized for its important work in helping Medicare and Medicaid beneficiaries avoid, detect, and prevent health care fraud. The program recruits and trains retired professionals and other senior citizens about how to recognize and report instances or patterns of health care fraud. Through their work, SMPs not only protect seniors, they also help preserve the integrity of the Medicare and Medicaid programs. The activities of the SMP program also "enhance the financial, emotional, physical and mental well-being of older adults - thereby increasing their capacity to maintain security and independence in retirement, and to make better financial and healthcare choices."

In choosing this year's awardee, NHCAA was impressed by SMP's quantifiable achievements. In 2009, its staff and force of more than 4,400 volunteers held over 7,100 group education sessions and more than 33,800 individual counseling sessions. It has also fielded over 60,000 inquiries, referring 966 of those inquiries to authorities for further action. And its cooperation with authorities in every state, territory and the District of Columbia has been critical to raising awareness among seniors about Medicare fraud and what they can do to help combat it. Overall, the Senior Medicare Patrol's efforts have helped Medicare, Medicaid and other payers save $101 million since 1997, monies that would otherwise have been lost to fraudulent claims.

NHCAA is proud to award and recognize SMP and its administrators for performing these invaluable services for our nation's seniors.

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2010 Investigative Excellence Award

Presented to

Capital BlueCross

An intensive two-year fraudulent billing practices investigation concluded on June 15, 2010, when the physician at the center of the case was sentenced to eight years' imprisonment, three years supervised release and ordered to pay over $7 million in restitution to various health plans defrauded in the scheme. Uncovered by Capital BlueCross, it was determined that the provider, Saroj Parida, M.D. was billing for interpreting comprehensive sleep studies when, in fact, he was reviewing recordings of respiration and heart rates produced by home apnea monitors used to ensure the safety of premature infants while they slept. These interpretations are reimbursed at a lower level than the comprehensive studies billed by Parida. Data analysis also showed that he was billing for reviewing recordings on infants not yet born and for months after the equipment had been removed by the DME supplier. The investigation identified other health plans victimized by the same scheme when it was determined that DME suppliers in other states were sending recordings to Parida for interpretation. Capital BlueCross contacted the special investigations units of these plans, asking them to request Parida's interpretation reports from the DME suppliers. Review of these documents provided the additional evidence necessary to demonstrate the extent of the scheme and its multiple victims.

Congratulations to

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Kathleen A. Amato, RN, BSN, CPC, CPC-H, AHFI
Director, Special Investigations

Angela M. Shoop, CPC
Special Investigator

Tina M. Beall, RN, BSN, CPC, CPC-H
Clinical Special Investigator

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2010 Medical Director Award

Presented to

Edwin C. Fischl, MD, MS, MBA, AHFI
Medical Director, Medical Management & Policy
Highmark Blue Cross Blue Shield

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Dr. Fischl's accomplishments in the health care anti-fraud field are well documented and profound.

Dr. Fischl has assisted in more than 450 cases-reviewing medical records and claims, assisting with onsite audits, spearheading revisions to medical policy and providing invaluable information and training to law enforcement. He has worked with Highmark's Financial Investigation and Provider Review department on many prominent cases, including:

  • The well-known 2005 Rent-a-Patient investigation, for which Dr. Fischl traveled to Arizona with investigators to interview and examine patients as part of this investigation. This case had national impact.
  • A case involving a laser vein practice where over-payments and over-utilization were alleged. Dr. Fischl participated in an onsite visit and determined that many of the services provided were cosmetic in nature and not medically necessary. His work led to a medical policy change that resulted in saving his company and its enrollees $2 million.
  • A case involving a chiropractor who organized a fictitious practice group and conspired to split fees with patients. Dr. Fischl reviewed volumes of office records, determining that they did not support the submitted E&M procedure codes. He then assisted the prosecutors, which resulted in the chiropractor, office manager and 15 members of the group pleading guilty and agreeing to pay $7 million in restitution.

Dr. Fischl is generous with his knowledge, having served several times as a speaker and educator for NHCAA. In addition to being a board-certified general surgeon, Dr. Fischl has a Master of Business Administration and has earned the Accredited Health Care Fraud Investigator (AHFI) designation, one of a very few physicians to do so.

Senior Vice President and Chief Medical Officer for Highmark Donald R. Fischer, MD writes of Dr. Fischl: "His insights, integrity, and willingness to collaborate have been key success factors for our program."

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