Eight Individuals Arrested for Bribery, Conspiracy, Health Care and Mail Fraud

Yesterday, a federal grand jury returned a 14 count indictment against eight individuals for bribery, conspiracy to commit health care fraud, conspiracy to commit an offense against the United States, mail fraud and aggravated identity theft, announced U.S. Attorney Rosa Emilia Rodríguez-Vélez for the District of Puerto Rico.  The investigation was led by the U.S. Department of Health and Human Services-Office of Inspector General (HHS-OIG), with the collaboration of the Federal Bureau of Investigation, U.S. Secret Service, U.S. Postal Inspection Service and the Puerto Rico Department of Health Medicaid Anti-Fraud Unit.

The Medicaid Program (Medicaid) is a federal health benefit program intended to provide benefits to low-income individuals and families. Medicaid is monitored and funded by the U.S. Department of Health and Human Services (HHS) through its agency, the Centers for Medicare and Medicaid Services (CMS).  In the Commonwealth of Puerto Rico, Medicaid is referred to in Spanish as “Mi Salud,” or “Plan de Salud del Gobierno” (PSG). Mi Salud beneficiaries included Medicaid participants and “state only funded health care recipients,” commonly referred to as “Commonwealth participants.”  An individual’s eligibility for Medicaid or Commonwealth health care benefits depends on certain eligibility requirements.

Although Medicaid is federally-funded, it is administered by the states and/or United States territories, including the Commonwealth of Puerto Rico.  HHS provided the Puerto Rico Department of Health (PR-DOH) approximately $1 billion annually to fund and/or reimburse the costs of Medicaid.

Within the PR-DOH, the Office of the Medicaid Program, also known in Spanish as “Programa De Asistencia Médica,” or “Programa De Medicaid,” was responsible for handling applications for Medicaid as well as the Commonwealth health plan eligibility, certification and recertification process.  Medicaid and the Commonwealth health plan eligibility was determined by a Program Technician, a government employee from the Programa de Asistencia Medica.

The indictment charges three agents of the Programa de Asistencia Medica Santurce Office with receiving monetary bribes in exchange for certifying individuals as eligible to receive Medicaid health care benefits.  The charged agents the Programa de Asistencia Medica are:Luis González-Cordova, a clerk in the Santurce office who dealt with Mi Salud participant files and individual applicants that sought Mi Salud benefits; Karen Curet-Nieves, a program technician in the Santurce office who evaluated and determined the eligibility of Mi Salud applicants, input data in the MEDITI system and approved Mi Salud benefits for participants; and Orlando Negrón-Bonilla, a program technician in the Santurce office who evaluated and determined eligibility of Mi Salud applicants, input data in the MEDITI system and approved Mi Salud benefits for participants.

The indictment alleges that from on or about July 9, 2014, through on or about Oct. 10, 2015, González-Cordova, Curet-Nieves and Negrón-Bonilla aiding and abetting one another, did corruptly solicit, demand, accept and agree to accept a thing of value from a person, to wit, cash payments, intending to be influenced and rewarded in connection with a transaction and series of transactions of Programa De Asistencia Médica involving $5,000 or more.  Rather, than abiding by their duties to ensure participants were in fact low-income and eligible for Medicaid, defendants abdicated those responsibilities in exchange for cash.  Those defendants and various “runners” are also charged with conspiracy to commit an offense against the United States, conspiracy to commit health care fraud, mail fraud and aggravated identity theft .

During the course of the conspiracy and scheme, defendants Ruben Escalera-Rivera, Perfecto De Leon-Toribio, Luis Caceres-De Leon, Luis Angel Garcia-Rosa and Andrea Jimenez-De Jesús, acted as “runners,” soliciting and referring individuals to defendant Luis González-Cordova for their fraudulent entry into the Medicaid health care benefit programs.  The runners would recruit individuals to be fraudulently enrolled into the Medicaid health care benefits programs in exchange for cash bribes and monetary payments without personally meeting with the individuals to determine their eligibility as required by PR-DOH procedures.  The runners delivered cash bribes to González-Cordova and upon receiving the personal identification information, including names, social security numbers, dates of birth and addresses, from the runners, González-Cordova would provide it to Curet-Nieves or Negrón-Bonilla by text or handwritten note for entry into the MEDITI database.  Curet-Nieves and Negrón-Bonilla fraudulently certified the participants as eligible to receive Medicaid health care benefits.

Curet-Nieves approved 20 to 30 unqualified individuals per week into the Mi Salud program for a fee of $10 each and Negrón-Bonilla approved 20 to 30 unqualified individuals per week into the Mi Salud program for a fee of $10  to $30 each.

The individually identifiable information for eligible participants was transferred daily to the Puerto Rico Health Insurance Administration, known in Spanish as Administración de Seguros de Salud de Puerto Rico (ASES), in order to complete the enrollment process with the various contracted Managed Care Organizations (MCO’s).  Medicaid health insurance cards for the MCO’s were then sent via regular mail to the participant.

ASES paid monthly premiums to the MCOs for the purposes of providing Medicaid health care benefits.  Monthly premiums were paid to MCO’s regardless of whether the participant required medical care services.  MCO’s also received federal monies for utilization of the health care plan.  As a result, each participant fraudulently certified as eligible for Medicaid health care benefits would result in the fraudulent payment of federal Medicaid funds to MCO’s.  This amount could range from hundreds to thousands of dollars per participant depending on the corresponding premiums and utilization.

In conjunction with this investigation, the Puerto Rico Department of Health Medicaid Anti-Fraud Unit is sending approximately 6,000 notification letters to participants whose eligibility has been identified as suspicious.  Over 130 participants have been mailed notifications already.

“Today’s arrests by HHS-OIG agents and our law enforcement partners show that we will not tolerate the improper use of health care program funds such as Medicaid which are essential to the welfare of low-income families in our community,” said U.S. Attorney Rodríguez-Vélez.  “The U.S. Attorney’s Office and federal law enforcement agencies will continue to investigate, charge and prosecute those who corruptly enrich themselves at the expense of the Medicaid program.

The Medicaid program provides health care benefits to low-income individuals and families, and the fraudulent enrollment of individuals into the program is unacceptable,” said Special Agent in Charge Scott Lampert of HHS-OIG New York Regional Office.  HHS-OIG and its law enforcement partners will continue to aggressively pursue to the fullest extent of the law those who seek to unlawfully enrich themselves by defrauding Medicaid.”

The case is being prosecuted by Assistant U.S. Attorney Luke Cass and Assistant U.S. Attorney Seth Erbe.  The case was investigated by U.S. Department of Health and Human Services-Office of Inspector General, with the collaboration of the Federal Bureau of Investigation, U.S.  Secret Service, U.S. Postal Inspection Service, the Puerto Rico Department of Health Medicaid Anti-Fraud Unit and the Puerto Rico Police Department.

If convicted, the defendants face a sentence of up to twenty years of imprisonment plus a mandatory two year term of imprisonment for aggravated identity theft.  Criminal indictments are only charges and are not evidence of guilt.  A defendant is presumed innocent unless and until proven guilty.